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Ocular Emergencies

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.

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Ocular Emergencies

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  1. Ocular Emergencies

  2. 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

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

  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. 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

  20. 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

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

  22. 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

  23. 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

  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. Periorbital Cellulitis 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

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

  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. Glaucoma 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

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

  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. 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

  32. 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

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

  36. 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

  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. 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

  39. Extraocular Foreign Body 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

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

  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. 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

  43. 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

  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. 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

  46. 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

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

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

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

  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

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