Eye Emergencies from EM physician

1. Eye Emergencies
Abdulrahman F. Al-Balais
R1

2. Anatomy
• Orbit borders:
Superior: frontal sinus
Medial: ethmoid sinus
Inferior: maxillary sinus
Lateral: zygomatic bone(paper thin most likely
to be perforated)

3. Anatomy
• Orbital septum: Anterior limit of orbital cavity.
• Impervious to bacteria; limits spread of
infection.
• Arterial blood supply: ophthalmic artery.
• Venous drainage: ophthalmic veins

5. Anatomy
• Layers of eye:
• Conjuctiva: transparent mucous membrane
• Episclera: thin layer of elastic tissue;contain blood
vessels that nourish the sclera.
• Sclera: collagenous protective layer.
• Cornea: five layers; Epithelium(five layers thick),
Bowman, Stroma, Descemet membrane,
Endothelium.
• Uveal tract( iris, ciliary body,choroid)

7. Eye Assesment
• History:
• Vision loss, appearance, pain, dicomfort, pruritus, trauma.
• Onset of symptoms, duration, circumstances surrounding onset, pmh.
• Examination:
• Visual Acuity: done using a snellen chart with the patient standing at 20ft(6m).
• Confrontation visual fields.
• Ocular motility: to check extraocular muscles movements( LR6, SO4, ALL OTHERS
CONTROLLED BY CN3).
• Pupils: check size, shape, reaction to light.
• External eye: check periorbital skin, lids, eyebrows for signs of trauma, infection,
deformity.
• Slit lamp:conjuctiva(chemosis, injection,discharge, trauma, foreign
bodies),cornea(abrasions, ulcers,edema, foreign bodies), ant.chamber(depth,
hypopyon, hyphema).

12. Eye assesment
• Fluorescein examination:
• The final part of slit lamp examination to check for full thickness corneal laceration
after fluorecein is instilled into eye.

13. Eye assesment
• Funduscopy:
• Optic disk(size,shape), cup-to-disk ratio, ratio of arteries to veins( normal 2/3),
hemorrhages, exudates, aneurysms, size and shape of macula, papilledema(
edema of head of optic nerve due to high icp)
• Causes of papilledema: malignant htn, pseudotumor cerebri, hydrocephalus,
intracranial tumors)
• Dilation for funduscopy: one drop of 1% topicamide +/- 2.5% phenylephrine.
• Intraocular pressure:
• Normal intraocular pressure: 10-20mm/hg.

15. Ocular Infections and Inflammation
• Preseptal Cellulitis(periorbital):
• Infecton of eyelids and periorbital tissues anterior to orbital septum.
• Organisms: S.aureus, S.epidermidis, Streptococcus species, Anarobes.
• Disease of childhood <10 years
• Upper resp symptoms, fever, redness, swelling of eyelid, excessive tearing
• Tx: Augmentin or 1st generation cephalosporin, hot packs, close follow-up
• Severe cases and young children>>ophthalmology consultation.
• Postseptal cellulitis(orbital):
• Infection of orbital soft tissues posterior to orbital septum.
• Organisms: often polomicrobial with S. aureus, S.pneumoniae and anaerobs.
• In diabetics and immunocompromised>>> consider mucormycosis.
• Upper resp symptoms, facial pressure, fever, decreased visual aquity, chemosis, limited
extraocular movements.
• Tx: CT scan + urgent ophthalmology consultation.

18. Ocular Infections and Inflammation
• Conjuctivitis:
• Usually viral>>self limited
• Others: bacterial, fungal, parasitic, allergic, chemical.
• Bacterial: Tx: topical abx( Trimethoprim-polymyxin B) 4 times daily.
• Wearers of soft contact lense>>fluroquinolone or aminioglycoside to cover
pseudomonas.
• Viral: most common adenovirus>>selflimited with ocular decongestant(NAPHCON-
A), artificial tears and cold compressors.
• Allergic: eliminate offending allergen, cold compressors, artificial tears+/-topical
antihistamine or NSAIDS>>if severe symptoms>>refer to ophthalmologist but don’t
prescribe topical steroids.

20. Ocular Infections and Inflammation
• Cornea:
• Herpes simplex keratoconjuctivitis:
• Hx of genital herpes and photophobia, pain, decreased vision,redness.
• Injected conjuctiva, palpable preauricular lm.
• Dendrite of herpes keratitis seen with flurescein stain.
• Can lead to corneal scarring.
• Tx: oral acyclovir or famciclovir+/- topical trifluridine(1 drop 9 times a day) if conjuctival
involvment.
• Herpes zoster Ophthalmicus:
• Shingles involving first branch(V1) of trigeminal nerve.
• Fever, redness, pain and parasthesia in dermatome distribution, blurred vision,
photophobia.
• Keratitis, uvitis,retinitis,optic neuritis.
• Slit lamp: cells and flares of iritis.
• Tx: Acyclovir, Famciclovir, Valacyclovir…..cutaneus lesions>>erythromycin ointment

22. Ocular Infections and Inflammation
• Corneal ulcer:
• Serious infection involving multiple layers of cornea.
• High risk patients: Bells palsy>exposure keratitis, Trauma, S.pneumoniae S.aureus
infection, contact lens>pseudomonas.
• Redness, discharge, chemosis,foreign body sensation, pain, photophobia,
decreased visual acuity( if uveal tract is involved).
• Corneal exam: round/irregular ulcer+white hazy base. Hypopyon may be present.
• Tx: emergent ophthamology consultation for c/s
• Topical ciprofloxacin 1 drop every 4 hours+ cyclopegic(eg. Cyclopentolate 1%) for
pain.

24. Ocular Infections and Inflammation
• Hordeolum and chalazion:
• Hordeolum(stye): acute purulent infection of sebaceous glands caused by
S. aureus.
• It can be internal involving meibomian gland or external involving gland of
Zeis.
• S&S: erythematous and tender eyelid nodule
• Chalazion: chronic ganulomatous infection of an obstructed meibomian
gland that result from progression of a hordeolum.
• S&S: hard,rubbery and painless nodule, Lid margin is normal.
• Tx:
• Initial Tx is warm compressors of the eye for 15 min 4 times a aday.
• If persistant symptoms>>ophthalmology referral for surgical drainage.
• For hordeolum: erythromycin ophthalmic ointment twice daily for 10 days.

26. Eye Trauma
• Cornea:
• Corneal abrasion:
• Caused by: contact lens, nails, foreign bodies.
• Symptoms: pain, photophobia, tearing, sensation of foreign bodies.
• Signs: conjunctival injection, lid swelling, blepharospasm(use topical
anesthetic), decreased visual aquity.
• Slit lamp: superficial irregular corneal defect appearing bright green
under cobalt blue light.
• Seidel test –ve.
• If multiple small fine-lined vertical abrasions found>>foreign body
imbeded in upper lid.

29. Eye Trauma
• Corneal abrasion:
• Tx:
• Self-limiting, only symptomatic management.
• For pain>>Cyclopentolate 1% one drop TDS.
• Topical NSAIDS like Ketorolac or Diclofenac can be used.
• Never prescribe topical Anasthetic as they inhibit corneal
healing.
• Apply eye patch; unless caused by fingernails or contact
lens>>increase the risk of infection.
• Large abrasions or abrasions in central visual axis>>refer to
ophthalmologist.

31. Eye Trauma
• Corneal laceration:
• Same causes as abrasions + high speed machinary.
• Symptoms: pain out of proportion, tearing, photophobia .
• Signs: decreased visual aquity, misshapen iris, hyphema.
• Seidel test:+ve unless small lacerations which close
spontaeously.
• Tx: if suspect a penetrating injury>> urgent CT and
ophthalmology consultation.
• Small lacerations treated as simple abrasions.

33. Eye trauma
• Corneal foreign bodies:
• Usually superficial and benign>>if penetration into the globe>>
vision loss.
• High velocity projectiles>> globe penetration.
• Symptoms: foreign body sensation, tearing, blurred vision, diplopia,
photophobia.
• Signs: conjuctival injection, edema, rust ring(if a metallic foreign
body), hyphema(suggest globe perforation), seidel test (+ve if globe
penetration occurred).
• Tx: removal of foreign body and topical Abx.
• If full thickness corneal foreign body or rust ring>>ophthalmology
referral.

36. Eye Trauma
• Lid Laceration:
• Suspect corneal laceration or globe rupture with any full
thickness lid laceration.
• When to do urgent referral to ophthalmologist?
1. Involvement of lid margin.
2. Within 6-8mm of medial canthus or involving lacrimal duct.
3. Involvement of inner surface of lid.
4. Lacerations associated with ptosis, involving the tarsal plate
or levator palpebrae muscle(suspect with horizontal
lacerations with ptosis)

37. Eye Trauma
• Partial thickness lid lacerations not meeting the previous
criteria can be repaired in ED with referral to ophthalmologist
within 2-3 days.
• Use soft absorbable or non-absorbable 6-0 or 7-0 suture.
• Very small lacerations(<1mm) at lid edge only do not need
suturing as they heal spontaneously.

40. Blunt Eye Trauma
• Approach:
• Assess visual aquity, anterior chamber, integrity of globe.
• Open the lids with paper clips or eyelid speculum.
• Perform slit lamp exam looking for:
1. Flat anterior chamber.
2. Hyphema.
3. Abrasions.
4. Lacerations.
5. Foreign bodies.
6. Iris( cells and flares).
7. Lens dislocation.

41. Blunt Eye Trauma
• Check ocular motility>>if restricted upgaze or lateral
gaze>>blow-out-fracture with entrapment>>perform CT Facial
bone +/- CT Head.
• Measure IOP(if no signs of ruptured globe).
• Test for pupillary response.
• If vision, ocular anatomy and function preserved>>F/U
ophthalmology opd within 48 hours.
• If ruptured globe suspected due to: flat ant.chamber,
hyphema, loss of visual aquity, full thickness lacerations,
foreign bodies>>immediate ophthalmology referral.

45. Orbital blow-out Fractures
• Most common sites are the inferior wall(maxillary sinus) and
medial wall(ethmoid sinus).
• Fractures of medial wall>>Subcutaneous emphysema.
• Fractues of inferior wall>>entrapment of inferior rectus
muscle and diplopia.
• One third of cases are associated with ocular trauma(
abrasions, lacerations, hyphema, retinal tear, detachment)
• Diagnosis confirmed by CT scan.
• All blow-out fracture cases should be referred to
ophthalmologist to r/o retinal tear or detachment.
• Prophylactic oral Abx(Cephalexin 250mg PO QID for 10 days).

47. Ruptured Globe
• Results from any object that causes sudden elevation of IOP.
• Hx of blunt trauma, penetrating
trauma(bullets,knives,darts,hammering use of high speed
machinery).
• Eye pain +/- decreased visual aquity.
• Subconjuctival hemorrhage, peri-orbital ecchymosis, blow-out
fractures, puncture or laceration of eyelid, corneal abrasions,
irregular shaped pupil, afferent pupillary defect, uvual
prolapse, +ve seidel test.
• Imaging of choice>>CT scan.

48. Ruptured Globe
• If globe rupture is obvious or highly suspected>>cover the eye
and consult ophthalmologist immediately.
• Administer broad-spectrum Abx, raise the head 45 degrees,
provide analgesia.
• Avoid topical eye solutions, Don’t measure IOP>>can result in
extrusion of globe contents.

51. Orbital Hemorhages
• Pre&post septal hemorrhages: caused by severe blunt trauma
to the orbit.
• To differntiate>>examination and non-contrast orbital CT.
• Post septal hemorrhage(Retrobulbar Hematoma) associated
with(pain, proptosis,impaired extraocular
movements,decreased vision,elevated IOP).
• Post septal hemorrhage is a true emergency>>urgent
ophthalmology referral.
• If IOP>40mm/hg>>Emergency lateral canthotomy should be
performed.

53. Lateral Canthotomy

55. Chemical ocular injury
• Alkali injuries occur more frequently than Acid injuries.
• Most serious associated with ammonia(found in household
cleaners) and Lye(found in drain cleaners).
• More serious than acid injuries because they cause
Liquifaction injury(allowing deep penetration into tissues).
• Most serious complication of chemical ocular injury is scarring
of cornea>>permenant loss of vision due to perforation.

56. Chemical ocular injury
• Approach:
• Irrigation Irrigation Irrigation.
• Irrigate with sterile normal saline for at least 30 minutes then
check ph with litmus paper>>if ph>7.4>>continue irrigation
for 30 more minutes.
• After irrigation and maintainance of ph>7.4>>perform
thorough ocular examination.
• Inspect facial skin and eyelids for burns, check visual aquity,
check for foreign bodies,check IOP.
• Perform slit lamp exam(corneal injury, cells and flare).

57. Chemical ocular injury
• Approach:
• Obtain urgent ophthalmology consultation to all but minor
burns( esp in case of corneal clouding or epithelial defect).
• Patients with chemosis(edema of bulbar conjuctiva) and no
corneal or anterior chamber findings should be treated with
erythromycin ointment 4 times daily and topical cycloplegic 3
times daily.
• Avoid Phenylephrine as cycloplegic >>constricts blood vessels.

59. Acute visual Reduction/Loss

60. Acute Angle-Closure Glaucoma
• Pathophysiology:
• Lens or peripheral iris blocks the Trabecular meshwork
obstructing outflow of aqueous humor.
• Results in pressure differential between posterior and
anterior chamber(pupillary block) causing forward bowing of
iris.

61. Acute Angle-Closure Glaucoma
• Acute attack precipitated by pupillary dilatation, which
increase the contact between the iris and lens(as it becomes
thicker).
• This increases the degree of pupillary block, increasing
pressure in posterior chamber>>bulging of iris(iris bombe)
and increased IOP.
• Triggers of acute attack:
1. Use of topical or systemic parasympatholetic
agents(mydriatics,antihistamines).
2. Sympathomimetics(epinephrine,pseudoephedrine).
3. Use of intranasal cocaine.
4. Nebulized B-sympathomimetics and anticolinergic meds.

63. Acute Angle-Closure Glaucoma
• Symptoms:
• Acute onset of severe eye pain or frontal headache.
• Blurred vision.
• Nausea and vomiting.
• Signs:
• Fixed midposition pupil.
• Hazy(cloudy) cornea with conjuctival injection.
• Affected eye is rock hard.
• Increased IOP.

65. Acute Angle-Closure Glaucoma
• Management:
• Goals of management:
1. Lowering IOP by blocking production of aqueous humor,
facilitating outflow of aqueous humor and reducing the
volume of vitreous humor.
2. Ophthalmology consultation.
3. Definitive treatment is Laser iridectomy.