Eye injuries

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

51. Hyphema
Symptoms/Assessment
 Blurred vision
 Blood tinged vision
 Pain
 Visualized blood in
anterior chamber at
bottom of iris
 Assess for other
associated injuries

52. Hyphema
Treatment/Education
 Have patient sit upright or
bedrest with HOB 30°
 Patch or shield both eyes
 Diuretics to decrease
intraocular pressure
 Refrain from taking aspirin
 Refer to ophthalmologist
 Admission

53. Eyelid Laceration
Symptoms/Assessment
 MOI
 Visual disturbance
 Laceration
 Protrusion of fat
 Upper lid does not raise
 Assess for ocular injuries
 Bleeding
Treatment/Education
 Stop bleeding: Avoid
direct pressure on the eye
 Surgical repair
 Topical analgesic
 Td
 Wound care
 S/S of infection
 Follow-up

54. Globe Rupture
 Ocular Emergency
 Penetrating or perforating injury

55. Globe Rupture
Symptoms/Assessment
 MOI
 Blunt
 Penetrating
 Sudden visual impairment or
loss
 Pain
 Asymmetry of globe
 Extrusion of aqueous or
vitreous humor
 Direct visualization of FB
 Irregularities in pupillary
borders
 Diagnostics
 CT scan
 MRI
 Orbit films
 Slit-lamp exam

56. Globe Rupture
Treatment
 Ophthalmological referral
 Do not open eye
 Keep patient in Semi-
Fowlers position
 Patch/shield affected both
eyes
 IV analgesics
 IV antibiotics
 Td
 Calm, supportive
environment
 Admission/Surgery
 If impaled object: Secure
it.
Do Not
Remove IT!