Ocular Emergencies Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital
Ocular Anatomy
1.  Frontal  bone 2.  Zygomatic  bone 3.  Maxillary  bone 4.  Sphenoid  bone 5.  Ethmoid  bone 6.  Lacrimal  bone 7.  Pala...
Paranasal Sinus
Ocular Anatomy Orbicularis Oculi
Ocular Anatomy
Ocular Anatomy
Ocular Anatomy
Extraocular Muscles
Optic Nerve
Venous System
Ocular Emergencies Trauma Non - trauma Blunt trauma Penetrating trauma
Retinal arterial  Perforation   Orbital cellulitis occlusion   Ruptured   Orbital injury Chemical burns     Acute glaucoma...
Ocular condiitons requiring immediate  treatment Acute Angle-Closure Glaucoma Central Retinal Artery Occlusion Orbital  Ce...
Ocular burns and trauma Ocular Burn Alkali Burns Acid Burns Thermal Burns Burns Due to Ultraviolet Radiation Mechanical Tr...
Eye Examination Visual acuity  External Eye : orbit, periorbital skin, eyelids Confrontation visual fields Ocular motility
Anterior Segment Conjunctiva Cornea Anterior chamber Iris  Lens Pupils  :  RAPD Eye Examination
A dilated pupil makes it easier to see the optic nerve, macula, and retina -  1% tropicamide ( Mydriacyl ) -  2.5% phenyle...
Digital palpation Schiotz tonometer Intraocular Pressure Measurement
Ocular Trauma Closed Globe Open Globe Burn Contusion Laceration Laceration Penetrating Perforating Rupture
<ul><li>Causes </li></ul><ul><li>Trauma,  Hypertension </li></ul><ul><li>Valsava pressure spikes </li></ul><ul><li>Spontan...
Pain , photophobia ,  FB sensation, tearing Conjunctival injection,  swollen eyelid Corneal Abrasion Epithelial staining d...
<ul><li>Topical cycloplegia, ATB ointment </li></ul><ul><li>Pressure patching for 24 hours </li></ul><ul><li>Searching for...
Corneal Ulcer Hypopyon Eye Shield No patching Topical antibiotics Ophthalmologist referral
Conjunctival Foreign Bodies
Corneal foreign body with rust ring Rust ring Corneal Foreign Bodies
<ul><li>Remove the FB under the best magnification </li></ul><ul><li>Evert the eyelid to rule out additional FB </li></ul>...
Corneal Foreign Body Removal
<ul><li>Disruption of blood vessels in the iris or ciliary body </li></ul><ul><li>Blood in anterior chamber </li></ul>Trau...
Traumatic Hyphema : Classification Total  IV  1/2  to less than total III  1/3  to  1/2 II  Less than  1/3 I  No layered b...
Traumatic Hyphema
<ul><li>Elevate the patient’s head </li></ul><ul><li>Bed rest </li></ul><ul><li>1% atropine one drop 3-4 times daily </li>...
<ul><li>Rebleeding can occur 3 to 5 days later in 30% </li></ul><ul><li>Uncontrolled glaucoma or blood stained cornea  </l...
<ul><li>Sharp or blunt trauma </li></ul><ul><li>R/O associated ocular injury </li></ul><ul><li>Remove superficial FB </li>...
Full Thickness Lid Lacerations -  Gray line -  Lash line -  Mucocutaneous junction Tear lid margin
Laceration of lower eyelid margin Post-operative result following a primary repair Lid Margin Repair
<ul><li>Refer to ophthalmologist if there are  </li></ul><ul><li>associated ocular injuries </li></ul>Lid Lacerations <ul>...
Lid Lacerations   with tear canaliculi
Canalicular Repair
<ul><li>Woman with tearing and medial canthal asymmetry after the repair of a laceration sustained during a domestic assau...
Penetrating / Ruptured Globe  <ul><li>Corneal or scleral lacerations </li></ul><ul><li>Hypotony (not always present) </li>...
Irregular pupil
Penetrating / Ruptured Globe
Ruptured globe caused by golf ball Penetrating / Ruptured Globe
<ul><li>Stop examination </li></ul><ul><li>Shield the eye (do not patch) </li></ul><ul><li>Give tetanus prophylaxis </li><...
Intraocular or Intraorbital Foreign Bodies
Ocular Trauma Traumatic cataract Traumatic mydriasis Traumatic lens subluxation Traumatic lens subluxation
<ul><li>True ocular emergency  </li></ul><ul><li>Both acid and alkali burns can be blinding </li></ul><ul><li>-  Acid burn...
<ul><li>Immediate copious irrigation with a minimum of  </li></ul><ul><li>1-2 L of saline or until pH is normalized ( 7.3-...
Irrigation in case of chemical injury
<ul><li>Immediate copious irrigation with a minimum of  </li></ul><ul><li>1-2 L of saline or until pH is normalized ( 7.3-...
Chemical Ocular Injury : Classification  Grade I Grade II Grade III Grade IV
Chemical Ocular Injury : Management  <ul><li>Preservative-free artificial tears  </li></ul><ul><li>Topical non-preserved s...
Bilateral Alkali Injuries Chemical Ocular Injury
Chemical Ocular Injury : Management  Corneal Transplantation Keratoprosthesis
<ul><li>Accidental into the eye can cause the lids to  </li></ul><ul><li>adhere and adhesive clumps to form on the cornea ...
<ul><li>Moisten the glue with eye ointment, and remove </li></ul><ul><li>as much as can be removed easily without causing ...
Non-traumatic Ocular Emergencies
The woman suddenly experienced nausea, vomiting, and extreme pain in the left eye while in a movie theater. Her vision has...
VA  -  HM Conjunctival injection Hazy cornea Shallow anterior chamber Fixed mid-dilated pupil  A 55-year-old woman with a ...
Anterior Chamber Depth
Reduce the intraocular pressure O.5% Timolol 1 drop  2-4 % Pilocarpine 1 drop every 15 minutes 20% Mannitol 250-500 ml IV ...
A 60-year-old woman with acute, painless loss of vision in the right eye Visual acuity  CF – LP   in 90% of cases Opaque w...
Treatment must be initiated immediately. Ocular massage Inhaled carbogen ( 95% O2 and 5% CO2 ) Reduced intraocular pressur...
A 40-year-old man with left eyelid edema and pain   ( worse on eye movement )
A 40-year-old man with left eyelid edema and pain   ( worse on eye movement ) <ul><li>Periorbital erythema and edema </li>...
Broad spectrum intravenous antibiotics CT scan orbit Ophthalmology & ENT consultation  Orbital Cellulitis Subperiosteal ab...
Preseptal Cellulitis
Endophthalmitis
Urgent Neuro-ophthalmology
A 36-year-old-woman with subacute visual loss in  right eye and pain on eye movement  VA  20/200, 20/25  RAPD +ve OD VF  c...
A 55-year-old man with HT and acute visual loss in RE  VA  20/100, 20/20  RAPD +ve RE  Nonarteritic anterior ischemic opti...
A 73-year-old woman with acute visual loss of right eye, headache, anorexia and weight loss VA  10/200, 20/25  RAPD + ve R...
Pathology : Giant Cell ( Temporal ) Arteritis
A 35-year-old man with left painful third nerve palsy  VA  20/25, 20/30  Dilated, nonreactive pupil LE
A 35-year-old man with a suspicious of aneurysmal third nerve palsy  Conventional CT scan or MRI are not the procedure of ...
A 35-year-old man with a suspicious of aneurysmal third nerve palsy
A 40-year-old woman with sudden onset of left  third nerve palsy, visual loss and severe headache  What is the diagnosis? ...
Pituitary Apoplexy Characterized by sudden visual loss, headache, and ophthalmoplegia  secondary to rapid expansion of pit...
A 17-year-old man with right blured vision after  minor blunt trauma.  VA  20/32,  20/20  + ve RAPD RE Normal fundi  RE LE
A 16-year-old man with head injury and left blured vision after falls from height  VA  20/30,  LP  + ve RAPD LE  Normal fu...
Traumatic Optic Neuropathy :  Classification and Mechanisms Direct injury   -  Penetrating injury from knife, projectile -...
Clinical Features of Traumatic Optic Neuropathy Most commonly unilateral May be overlooked in setting of significant globe...
Medical Management Options Steroids : Controversial -  Thought to limit free-radical amplification  of the injury response...
Surgical Management Options Lateral canthotomy and cantholysis for orbital hemorrhage Surgical decompression of the optic ...
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  • Ocular Emergency

    1. 1. Ocular Emergencies Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital
    2. 2. Ocular Anatomy
    3. 3. 1. Frontal bone 2. Zygomatic bone 3. Maxillary bone 4. Sphenoid bone 5. Ethmoid bone 6. Lacrimal bone 7. Palatine bone 1 2 3 4 5 6 7 Bony Components of Orbit Size 30 x 40 x 45 mm
    4. 4. Paranasal Sinus
    5. 5. Ocular Anatomy Orbicularis Oculi
    6. 6. Ocular Anatomy
    7. 7. Ocular Anatomy
    8. 8. Ocular Anatomy
    9. 9. Extraocular Muscles
    10. 10. Optic Nerve
    11. 11. Venous System
    12. 12. Ocular Emergencies Trauma Non - trauma Blunt trauma Penetrating trauma
    13. 13. Retinal arterial Perforation Orbital cellulitis occlusion Ruptured Orbital injury Chemical burns Acute glaucoma Corneal ulcer Sudden congestion Corneal abrasion proptosis Hyphema Intraocular FB Retinal detachment Macular edema ( Immediately ) ( Within a few hours ) ( Within one day ) Acute Eye Conditions Emergency Very Urgent Urgent
    14. 14. Ocular condiitons requiring immediate treatment Acute Angle-Closure Glaucoma Central Retinal Artery Occlusion Orbital Cellulitis Cavernous Sinus Thrombosis Endophthalmitis Retinal Detachment Toxic Causes of blindness Nontraumatic Ocular Emergencies Acute Dacryocystitis Acute Dacryoadenitis Acute Hordeolum Preseptal cellulitis Spontaneous subconjunctival hemorrhage Conjunctivitis Bacterial corneal ulcer Viral keratoconjunctivitis Acute hydrops of the cornea Hyphema Uveitis ( iritis & iridocyclitis ) Vitreous hemorrhage Retinal hemorrhage Central retinal vein occlusion Optic neuritis Ocular Emergencies
    15. 15. Ocular burns and trauma Ocular Burn Alkali Burns Acid Burns 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 Ocular Emergencies
    16. 16. Eye Examination Visual acuity External Eye : orbit, periorbital skin, eyelids Confrontation visual fields Ocular motility
    17. 17. Anterior Segment Conjunctiva Cornea Anterior chamber Iris Lens Pupils : RAPD Eye Examination
    18. 18. A dilated pupil makes it easier to see the optic nerve, macula, and retina - 1% tropicamide ( Mydriacyl ) - 2.5% phenylephrine ( Neo-Synephrine ) Fundus Examination PanOptic Ophthalmoscope Indirect Ophthalmoscope
    19. 19. Digital palpation Schiotz tonometer Intraocular Pressure Measurement
    20. 20. Ocular Trauma Closed Globe Open Globe Burn Contusion Laceration Laceration Penetrating Perforating Rupture
    21. 21. <ul><li>Causes </li></ul><ul><li>Trauma, Hypertension </li></ul><ul><li>Valsava pressure spikes </li></ul><ul><li>Spontaneous </li></ul>No treatment Resolve within 2 weeks Subconjunctival Hemorrhage
    22. 22. Pain , photophobia , FB sensation, tearing Conjunctival injection, swollen eyelid Corneal Abrasion Epithelial staining defect with fluorescein
    23. 23. <ul><li>Topical cycloplegia, ATB ointment </li></ul><ul><li>Pressure patching for 24 hours </li></ul><ul><li>Searching for conjunctival foreign body </li></ul>Don’t apply PP if there is a significant risk of infection. Corneal Abrasion : Management
    24. 24. Corneal Ulcer Hypopyon Eye Shield No patching Topical antibiotics Ophthalmologist referral
    25. 25. Conjunctival Foreign Bodies
    26. 26. Corneal foreign body with rust ring Rust ring Corneal Foreign Bodies
    27. 27. <ul><li>Remove the FB under the best magnification </li></ul><ul><li>Evert the eyelid to rule out additional FB </li></ul><ul><li>Treat resulting corneal abrasion </li></ul><ul><li>Referral to ophthalmologist, next day </li></ul>Residual rust ring Corneal Foreign Bodies
    28. 28. Corneal Foreign Body Removal
    29. 29. <ul><li>Disruption of blood vessels in the iris or ciliary body </li></ul><ul><li>Blood in anterior chamber </li></ul>Traumatic Hyphema
    30. 30. Traumatic Hyphema : Classification Total IV  1/2 to less than total III  1/3 to 1/2 II  Less than 1/3 I  No layered blood circulating red blood cells only 0 Size of Hyphema Grade 
    31. 31. Traumatic Hyphema
    32. 32. <ul><li>Elevate the patient’s head </li></ul><ul><li>Bed rest </li></ul><ul><li>1% atropine one drop 3-4 times daily </li></ul><ul><li>1% prednisolone acetate one drop 3-4 times daily </li></ul><ul><li>If the globe is intact, measure IOP </li></ul><ul><li>Reduce IOP </li></ul><ul><li>Ophthalmology consult </li></ul>Traumatic Hyphema : Management
    33. 33. <ul><li>Rebleeding can occur 3 to 5 days later in 30% </li></ul><ul><li>Uncontrolled glaucoma or blood stained cornea </li></ul><ul><li>requires anterior chamber “wash out” </li></ul>Traumatic Hyphema : Management
    34. 34. <ul><li>Sharp or blunt trauma </li></ul><ul><li>R/O associated ocular injury </li></ul><ul><li>Remove superficial FB </li></ul><ul><li>Rule out deeper FB </li></ul><ul><li>Give tetanus prophylaxis </li></ul>Lid Lacerations
    35. 35. Full Thickness Lid Lacerations - Gray line - Lash line - Mucocutaneous junction Tear lid margin
    36. 36. Laceration of lower eyelid margin Post-operative result following a primary repair Lid Margin Repair
    37. 37. <ul><li>Refer to ophthalmologist if there are </li></ul><ul><li>associated ocular injuries </li></ul>Lid Lacerations <ul><li>Ruptured globe </li></ul><ul><li>Lacrimal drainage system </li></ul><ul><li>Levator aponeurosis </li></ul><ul><li>Medial canthal tendon </li></ul><ul><li>Tissue loss ( > 1/3 ) </li></ul>
    38. 38. Lid Lacerations with tear canaliculi
    39. 39. Canalicular Repair
    40. 40. <ul><li>Woman with tearing and medial canthal asymmetry after the repair of a laceration sustained during a domestic assault </li></ul>Tear Canthal Tendon
    41. 41. Penetrating / Ruptured Globe <ul><li>Corneal or scleral lacerations </li></ul><ul><li>Hypotony (not always present) </li></ul><ul><li>Severe chemosis & hemorrhage </li></ul><ul><li>Intraocular contents may be outside the globe </li></ul><ul><li>Limitation of extraocular motility </li></ul><ul><li>Shallow anterior chamber </li></ul><ul><li>Irregular pupil </li></ul>
    42. 42. Irregular pupil
    43. 43. Penetrating / Ruptured Globe
    44. 44. Ruptured globe caused by golf ball Penetrating / Ruptured Globe
    45. 45. <ul><li>Stop examination </li></ul><ul><li>Shield the eye (do not patch) </li></ul><ul><li>Give tetanus prophylaxis </li></ul><ul><li>NPO and systemic antibiotics </li></ul><ul><li>Do not apply eye ointment or eye drop </li></ul><ul><li>Film orbit if IOFB can’t be R/O </li></ul><ul><li>Refer immediately to ophthalmologist </li></ul>Penetrating / Ruptured Globe : Management
    46. 46. Intraocular or Intraorbital Foreign Bodies
    47. 47. Ocular Trauma Traumatic cataract Traumatic mydriasis Traumatic lens subluxation Traumatic lens subluxation
    48. 48. <ul><li>True ocular emergency </li></ul><ul><li>Both acid and alkali burns can be blinding </li></ul><ul><li>- Acid burns tend to coagulate proteins, limiting </li></ul><ul><li>the depth of penetration. </li></ul><ul><li>- Alkali burns can rapidly penetrate the cornea, </li></ul><ul><li>causing damage to intraocular structures. </li></ul>Chemical Ocular Injury
    49. 49. <ul><li>Immediate copious irrigation with a minimum of </li></ul><ul><li>1-2 L of saline or until pH is normalized ( 7.3-7.7 ) </li></ul><ul><li>- Instill a topical anesthetic </li></ul><ul><li>- Use eyelid retractor </li></ul><ul><li>- Double eversion of the eyelids </li></ul>Chemical Ocular Injury : Management
    50. 50. Irrigation in case of chemical injury
    51. 51. <ul><li>Immediate copious irrigation with a minimum of </li></ul><ul><li>1-2 L of saline or until pH is normalized ( 7.3-7.7 ) </li></ul><ul><li>- Instill a topical anesthetic </li></ul><ul><li>- Use eyelid retractor </li></ul><ul><li>- Double eversion of the eyelids </li></ul>Chemical Ocular Injury : Management <ul><li>Ophthalmologists Referral </li></ul><ul><li>No corneal involvement </li></ul><ul><li>- ATB + steroid eye drop </li></ul>
    52. 52. Chemical Ocular Injury : Classification Grade I Grade II Grade III Grade IV
    53. 53. Chemical Ocular Injury : Management <ul><li>Preservative-free artificial tears </li></ul><ul><li>Topical non-preserved steroid </li></ul><ul><li>Topical cycloplegic </li></ul><ul><li>Topical antibiotics </li></ul><ul><li>Oral analgesics </li></ul><ul><li>Pressure patch or bandage CL </li></ul><ul><li>Antiglaucoma + </li></ul>
    54. 54. Bilateral Alkali Injuries Chemical Ocular Injury
    55. 55. Chemical Ocular Injury : Management Corneal Transplantation Keratoprosthesis
    56. 56. <ul><li>Accidental into the eye can cause the lids to </li></ul><ul><li>adhere and adhesive clumps to form on the cornea </li></ul><ul><li>Not permanently harmful to the eye </li></ul><ul><li>Cyanoacrylates are used occasionally directly on the </li></ul><ul><li>cornea to seal corneal perforations. </li></ul>Cyanoacrylate Glue
    57. 57. <ul><li>Moisten the glue with eye ointment, and remove </li></ul><ul><li>as much as can be removed easily without causing </li></ul><ul><li>damage to underlying tissue </li></ul><ul><li>The glue will loosen and become easier to remove </li></ul><ul><li>in a few days. </li></ul>Cyanoacrylate Glue
    58. 58. Non-traumatic Ocular Emergencies
    59. 59. The woman suddenly experienced nausea, vomiting, and extreme pain in the left eye while in a movie theater. Her vision has worsened since that time and the eye has become very red. A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting
    60. 60. VA - HM Conjunctival injection Hazy cornea Shallow anterior chamber Fixed mid-dilated pupil A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting Acute Angle Closure Glaucoma IOP 56 mmHg
    61. 61. Anterior Chamber Depth
    62. 62. Reduce the intraocular pressure O.5% Timolol 1 drop 2-4 % Pilocarpine 1 drop every 15 minutes 20% Mannitol 250-500 ml IV drip Acetazolamide 500 mg oral 100% Glycerin 1 cc/kg Consult ophthalmologist Acute Angle Closure Glaucoma
    63. 63. A 60-year-old woman with acute, painless loss of vision in the right eye Visual acuity CF – LP in 90% of cases Opaque white retina and attenuated vessels Central Retinal Artery Occlusion
    64. 64. Treatment must be initiated immediately. Ocular massage Inhaled carbogen ( 95% O2 and 5% CO2 ) Reduced intraocular pressure Central Retinal Artery Occlusion Consult ophthalmologist immediately Anterior chamber paracentesis Direct infusion of t-PA or urokinase in the ophthalmic artery
    65. 65. A 40-year-old man with left eyelid edema and pain ( worse on eye movement )
    66. 66. A 40-year-old man with left eyelid edema and pain ( worse on eye movement ) <ul><li>Periorbital erythema and edema </li></ul><ul><li>Proptosis </li></ul><ul><li>Restricted extraocular motility </li></ul><ul><li>Decreased visual acuity </li></ul><ul><li>Chemosis </li></ul><ul><li>Fever </li></ul>Orbital Cellulitis
    67. 67. Broad spectrum intravenous antibiotics CT scan orbit Ophthalmology & ENT consultation Orbital Cellulitis Subperiosteal abscess
    68. 68. Preseptal Cellulitis
    69. 69. Endophthalmitis
    70. 70. Urgent Neuro-ophthalmology
    71. 71. A 36-year-old-woman with subacute visual loss in right eye and pain on eye movement VA 20/200, 20/25 RAPD +ve OD VF central scotoma OD Retrobulbar optic neuritis
    72. 72. A 55-year-old man with HT and acute visual loss in RE VA 20/100, 20/20 RAPD +ve RE Nonarteritic anterior ischemic optic neuropathy ESR 10 mm/hr
    73. 73. A 73-year-old woman with acute visual loss of right eye, headache, anorexia and weight loss VA 10/200, 20/25 RAPD + ve RE ESR 94 mm/hr, high level of C - reactive protein Arteritic anterior ischemic optic neuropathy
    74. 74. Pathology : Giant Cell ( Temporal ) Arteritis
    75. 75. A 35-year-old man with left painful third nerve palsy VA 20/25, 20/30 Dilated, nonreactive pupil LE
    76. 76. A 35-year-old man with a suspicious of aneurysmal third nerve palsy Conventional CT scan or MRI are not the procedure of choice High false negative rate 12 – 40 % Magnetic resonance angiography (MRA) Computed tomography angiography (CTA) Overall sensitivity up to 97 %
    77. 77. A 35-year-old man with a suspicious of aneurysmal third nerve palsy
    78. 78. A 40-year-old woman with sudden onset of left third nerve palsy, visual loss and severe headache What is the diagnosis? VA 20/30, LP +ve RAPD LE
    79. 79. Pituitary Apoplexy Characterized by sudden visual loss, headache, and ophthalmoplegia secondary to rapid expansion of pituitary macroadenoma into the suprasellar space and/or cavernous sinus Commonly results from hemorrhage into a pre-existing pituitary mass
    80. 80. A 17-year-old man with right blured vision after minor blunt trauma. VA 20/32, 20/20 + ve RAPD RE Normal fundi RE LE
    81. 81. A 16-year-old man with head injury and left blured vision after falls from height VA 20/30, LP + ve RAPD LE Normal fundi
    82. 82. Traumatic Optic Neuropathy : Classification and Mechanisms Direct injury - Penetrating injury from knife, projectile - Injury from fractured bone - Avulsion, transection Indirect injury - Contusion with transmission of force through bone - Compression secondary to orbital hemorrhage or intrasheath hemorrhage
    83. 83. Clinical Features of Traumatic Optic Neuropathy Most commonly unilateral May be overlooked in setting of significant globe or maxillofacial trauma Reduced visual acuity ( NLP to 20/20 ) Visual field defect : No pathognomonic defect Normal optic disc with development of optic atrophy
    84. 84. Medical Management Options Steroids : Controversial - Thought to limit free-radical amplification of the injury response - Dosages ( low, high, mega) - May be harmful Observation : 57% of untreated patients shown to have 3 lines or more acuity improvement
    85. 85. Surgical Management Options Lateral canthotomy and cantholysis for orbital hemorrhage Surgical decompression of the optic nerve within its canal There is no defined standard protocol of treatment for indirect optic nerve injury .
    86. 86. Thank you for your attention
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