om verma msc lecturer in medical surgical nursing

1. Ocular EmergenciesOcular Emergencies
OM VERMA
LECTURER IN MEDICAL SURGICAL NURSING

2. Ocular Emergencies

3. DEFINITIONDEFINITION
 It is define as eye emergency occurs any time youIt is define as eye emergency occurs any time you
have a foreign object or chemicals in eye, or whenhave a foreign object or chemicals in eye, or when
an injury or burn affects eye area.an injury or burn affects eye area.
According to LippincottAccording to Lippincott
 It is a condition swelling, redness, or pain in eyes.It is a condition swelling, redness, or pain in eyes.
Without proper treatment, eye damage can lead toWithout proper treatment, eye damage can lead to
a partial loss of vision or even permanenta partial loss of vision or even permanent
blindness.blindness.
According to luckmannAccording to luckmann

4. Con…………………………..Con…………………………..
 Eye Eye emergenciesemergencies include cuts, scratches, include cuts, scratches,
objects in the eye, burns, chemical exposure, andobjects in the eye, burns, chemical exposure, and
blunt injuries to the eye or eyelid. Certain eyeblunt injuries to the eye or eyelid. Certain eye
infections and other medical conditions, such asinfections and other medical conditions, such as
blood clots or glaucoma, may also need promptblood clots or glaucoma, may also need prompt
medical care.medical care.

5. Retinal arterial Perforation Orbital cellulitis
occlusion Ruptured Orbital injury
Chemical burns Acute glaucoma Corneal ulcer
Sudden congestion Corneal abrasion
proptosis ( abnormal protrusion or displacement an eye Hyphema
Intraocular FB
Retinal detachment
( Immediately ) ( Within a few hours ) ( Within one day )
Acute Eye ConditionsAcute Eye Conditions
EmergencyEmergency Very UrgentVery Urgent UrgentUrgent

6. HYPHEMA - POOLING AND COLLECTION OF BLOOD
INSIDE THE ANTERIOR EYE .
RETINAL DETACHMENT =

8. loss of vision
burning or stinging
pupils that are not the same size
one eye is not moving like the other
one eye is sticking out or bulging
eye pain
decreased vision
double vision
redness and irritation
light sensitivity
bruising around the eye
bleeding from the eye
blood in the white part of the eye
discharge from the eye
severe itching
new or severe headaches

9. Ocular EmergenciesOcular Emergencies
TraumaTrauma
Non - traumaNon - trauma
Blunt traumaBlunt trauma
Penetrating traumaPenetrating trauma

10. Eye ExaminationEye Examination
Visual acuityVisual acuity
External Eye : orbit, periorbital skin, eyelidsExternal Eye : orbit, periorbital skin, eyelids
Confrontation visual fieldsConfrontation visual fields
Ocular motilityOcular motility

11. Anterior SegmentAnterior Segment
ConjunctivaConjunctiva
CorneaCornea
Anterior chamberAnterior chamber
IrisIris
LensLens
Pupils : RAPDPupils : RAPD
Eye ExaminationEye Examination

12. A dilated pupil makes it easier to see the opticA dilated pupil makes it easier to see the optic
nerve, macula, and retinanerve, macula, and retina
- 1% tropicamide ( Mydriacyl )- 1% tropicamide ( Mydriacyl )
- 2.5% phenylephrine ( Neo-Synephrine )- 2.5% phenylephrine ( Neo-Synephrine )
PanOptic
Ophthalmoscope
Indirect
Ophthalmoscope
Fundus ExaminationFundus Examination

13. Digital palpationDigital palpation
Schiotz tonometerSchiotz tonometer
Intraocular Pressure MeasurementIntraocular Pressure Measurement

14. Ocular TraumaOcular Trauma
Closed Globe Open Globe
Burn
Contusion
Laceration Laceration
Penetrating Perforating
Rupture

15. Pain , photophobia ,
FB sensation (foriegn
body sensation)
, tearing
Conjunctival injection,
swollen eyelid
Epithelial staining defect with fluorescein
Corneal AbrasionCorneal Abrasion

16. Con………..Con………..
 Fluorescein is a synthetic organic compoundFluorescein is a synthetic organic compound
available as a dark orange / red powder solubleavailable as a dark orange / red powder soluble
in water and alcohol.in water and alcohol.
 Fluorescein staining will identify scratches fromFluorescein staining will identify scratches from
a foreign body, corneal ulcers (Figure 26.10 ) ,a foreign body, corneal ulcers (Figure 26.10 ) ,
and the "grape-like clusters" ofand the "grape-like clusters" of
herpetic infections herpetic infections

17. Topical cycloplegia, ATB ointment
Pressure patching for 24 hours
Searching for conjunctival foreign body
Don’t apply PP if there is a
significant risk of infection.
Corneal AbrasionCorneal Abrasion : Management: Management

18. Corneal UlcerCorneal Ulcer
Hypopyon
Eye Shield
No patching
Topical antibiotics
Ophthalmologist referral

19. Conjunctival Foreign BodiesConjunctival Foreign Bodies

20. Corneal foreign body with rust ring
Rust ring
Corneal Foreign BodiesCorneal Foreign Bodies

21. Remove the FB under the best magnification
Evert the eyelid to rule out additional FB
Treat resulting corneal abrasion
Referral to ophthalmologist, next day
Residual rust ring
Corneal Foreign BodiesCorneal Foreign Bodies

22. Corneal Foreign Body RemovalCorneal Foreign Body Removal

23.  Disruption of blood vessels in the iris or ciliary body
 Blood in anterior chamber
Traumatic HyphemaTraumatic Hyphema

24. Traumatic HyphemaTraumatic Hyphema

25. Elevate the patient’s head
Bed rest
1% atropine one drop 3-4 times daily
1% prednisolone acetate one drop 3-4 times daily
If the globe is intact, measure IOP
Reduce IOP
Ophthalmology consult
Traumatic Hyphema : ManagementTraumatic Hyphema : Management

26. Rebleeding can occur 3 to 5 days later in 30%
Uncontrolled glaucoma or blood stained cornea
requires anterior chamber “wash out”
Traumatic Hyphema : ManagementTraumatic Hyphema : Management

27. Sharp or blunt traumaSharp or blunt trauma
R/O associated ocular injuryR/O associated ocular injury
Remove superficial FBRemove superficial FB
Rule out deeper FBRule out deeper FB
Give tetanus prophylaxisGive tetanus prophylaxis
Lid LacerationsLid Lacerations

28. Tear lid margin
Full Thickness Lid LacerationsFull Thickness Lid Lacerations
- Gray line
- Lash line
- Mucocutaneous junction

29. Laceration of lower eyelid margin
Post-operative result following a
primary repair
Lid Margin RepairLid Margin Repair

30. Refer to ophthalmologist if there areRefer to ophthalmologist if there are
associated ocular injuriesassociated ocular injuries
Lid LacerationsLid Lacerations
Ruptured globeRuptured globe
Lacrimal drainage systemLacrimal drainage system
Levator aponeurosis ( thin ,tendon like shethLevator aponeurosis ( thin ,tendon like sheth
that conect the eye main opening muscle )that conect the eye main opening muscle )
Tissue loss ( > 1/3 )Tissue loss ( > 1/3 )

31. Lid LacerationsLid Lacerations with tear canaliculiwith tear canaliculi

32. Canalicular RepairCanalicular Repair

33. Tear Canthal TendonTear Canthal Tendon
Woman with tearing and medial canthalWoman with tearing and medial canthal
asymmetry after the repair of a lacerationasymmetry after the repair of a laceration
sustained during a domestic assaultsustained during a domestic assault

34. Penetrating / Ruptured GlobePenetrating / Ruptured Globe
Corneal or scleral lacerationsCorneal or scleral lacerations
Hypotony (not always present)Hypotony (not always present)
Severe chemosis & hemorrhageSevere chemosis & hemorrhage
Intraocular contents may be outside the globeIntraocular contents may be outside the globe
Limitation of extraocular motilityLimitation of extraocular motility
Shallow anterior chamberShallow anterior chamber
Irregular pupilIrregular pupil

35. Irregular pupilIrregular pupil

36. Penetrating / Ruptured GlobePenetrating / Ruptured Globe

37. Ruptured globe caused by golf ball
Penetrating / Ruptured GlobePenetrating / Ruptured Globe

38. Penetrating / Ruptured Globe : ManagementPenetrating / Ruptured Globe : Management
Stop examinationStop examination
Shield the eye (do not patch)Shield the eye (do not patch)
Give tetanus prophylaxisGive tetanus prophylaxis
NPO and systemic antibioticsNPO and systemic antibiotics
Do not apply eye ointment or eye dropDo not apply eye ointment or eye drop
Film orbit if IOFB can’t be R/OFilm orbit if IOFB can’t be R/O
Refer immediately to ophthalmologistRefer immediately to ophthalmologist

39. Intraocular or Intraorbital Foreign BodiesIntraocular or Intraorbital Foreign Bodies

40. Ocular TraumaOcular Trauma
Traumatic cataract
Traumatic mydriasis Traumatic lens subluxation
Traumatic lens subluxation

41. True ocular emergency
Both acid and alkali burns can be blinding
- Acid burns tend to coagulate proteins, limiting
the depth of penetration.
- Alkali burns can rapidly penetrate the cornea,
causing damage to intraocular structures.
Chemical Ocular InjuryChemical Ocular Injury

42. Immediate copious irrigation with a minimum of
1-2 L of saline or until pH is normalized ( 7.3-7.7 )
- Instill a topical anesthetic
- Use eyelid retractor
- Double eversion of the eyelids
Chemical Ocular Injury : ManagementChemical Ocular Injury : Management

43. Irrigation in case of chemical injuryIrrigation in case of chemical injury

44. Immediate copious irrigation with a minimum of
1-2 L of saline or until pH is normalized ( 7.3-7.7 )
- Instill a topical anesthetic
- Use eyelid retractor
- Double eversion of the eyelids
Chemical Ocular Injury : ManagementChemical Ocular Injury : Management
Ophthalmologists Referral
No corneal involvement
- ATB + steroid eye drop

45. Chemical Ocular Injury : ClassificationChemical Ocular Injury : Classification
Grade I Grade II
Grade III Grade IV

46. Chemical Ocular Injury : ManagementChemical Ocular Injury : Management
Preservative-free artificial tears
Topical non-preserved steroid
Topical cycloplegic
Topical antibiotics
Oral analgesics
Pressure patch or bandage CL
Antiglaucoma +

47. Bilateral Alkali Injuries
Chemical Ocular InjuryChemical Ocular Injury

48. Chemical Ocular Injury : ManagementChemical Ocular Injury : Management
Corneal Transplantation
Keratoprosthesis

49. Accidental into the eye can cause the lids to
adhere and adhesive clumps to form on the cornea
Not permanently harmful to the eye
Cyanoacrylates are used occasionally directly on the
cornea to seal corneal perforations.
Cyanoacrylate GlueCyanoacrylate Glue

50.  Moisten the glue with eye ointment, and remove
as much as can be removed easily without causing
damage to underlying tissue
 The glue will loosen and become easier to remove
in a few days.
Cyanoacrylate GlueCyanoacrylate Glue

51. Non-traumatic Ocular EmergenciesNon-traumatic Ocular Emergencies

52. The woman suddenly experienced nausea, vomiting, and extremeThe woman suddenly experienced nausea, vomiting, and extreme
pain in the left eye while in a movie theater. Her vision haspain in the left eye while in a movie theater. Her vision has
worsened since that time and the eye has become very red.worsened since that time and the eye has become very red.
A 55-year-old woman with a red eye, blurredA 55-year-old woman with a red eye, blurred
vision with halos, nausea, and vomitingvision with halos, nausea, and vomiting

53. VA - HMVA - HM
Conjunctival injectionConjunctival injection
Hazy corneaHazy cornea
Shallow anterior chamberShallow anterior chamber
Fixed mid-dilated pupilFixed mid-dilated pupil
A 55-year-old woman with a red eye, blurredA 55-year-old woman with a red eye, blurred
vision with halos, nausea, and vomitingvision with halos, nausea, and vomiting
Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma
IOP 56 mmHgIOP 56 mmHg

54. Anterior Chamber DepthAnterior Chamber Depth

55. Reduce the intraocular pressureReduce the intraocular pressure
O.5% Timolol 1 dropO.5% Timolol 1 drop
2-4 % Pilocarpine 1 drop every 15 minutes2-4 % Pilocarpine 1 drop every 15 minutes
20% Mannitol 250-500 ml IV drip20% Mannitol 250-500 ml IV drip
Acetazolamide 500 mg oralAcetazolamide 500 mg oral
100% Glycerin 1 cc/kg100% Glycerin 1 cc/kg
Consult ophthalmologistConsult ophthalmologist
Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

56. A 60-year-old woman with acute, painless lossA 60-year-old woman with acute, painless loss
of vision in the right eyeof vision in the right eye
Visual acuity CF – LPVisual acuity CF – LP in 90% of casesin 90% of cases
Opaque white retina and attenuated vesselsOpaque white retina and attenuated vessels
Central Retinal Artery OcclusionCentral Retinal Artery Occlusion

57. Treatment must be initiated immediately.Treatment must be initiated immediately.
Ocular massageOcular massage
Inhaled carbogen ( 95% O2 and 5% CO2 )Inhaled carbogen ( 95% O2 and 5% CO2 )
Reduced intraocular pressureReduced intraocular pressure
Central Retinal Artery OcclusionCentral Retinal Artery Occlusion
Consult ophthalmologist immediatelyConsult ophthalmologist immediately
Anterior chamber paracentesisAnterior chamber paracentesis
Direct infusion of t-PA or urokinase in theDirect infusion of t-PA or urokinase in the
ophthalmic arteryophthalmic artery

58. A 40-year-old man with left eyelid edema and painA 40-year-old man with left eyelid edema and pain
( worse on eye movement )( worse on eye movement )

59. A 40-year-old man with left eyelid edema and painA 40-year-old man with left eyelid edema and pain
( worse on eye movement )( worse on eye movement )
Periorbital erythema and edema
Proptosis
Restricted extraocular motility
Decreased visual acuity
Chemosis
Fever
Orbital CellulitisOrbital Cellulitis

60. Broad spectrum intravenous antibioticsBroad spectrum intravenous antibiotics
CT scan orbitCT scan orbit
Ophthalmology & ENT consultationOphthalmology & ENT consultation
Orbital CellulitisOrbital Cellulitis
Subperiosteal abscess

61. EndophthalmitisEndophthalmitis

62. Urgent Neuro-ophthalmologyUrgent Neuro-ophthalmology

63. Pathology : Giant Cell ( Temporal ) Arteritis

64. A 35-year-old man with left painful third nerve palsy
VA 20/25, 20/30
Dilated, nonreactive pupil LE

65. 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 %

66. 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

67. 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

68. 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

69.  If you getIf you get chemicalschemicals in your eye, you should take thein your eye, you should take the
following steps:following steps:
 Turn your head so the injured eye is down and to the side.Turn your head so the injured eye is down and to the side.
 Hold your eyelid open and flush with cool tap water forHold your eyelid open and flush with cool tap water for
15 minutes. This can also be done in the shower.15 minutes. This can also be done in the shower.
 If you are wearing contact lenses and they are still in yourIf you are wearing contact lenses and they are still in your
eye after flushing, try to remove them.eye after flushing, try to remove them.
 Get to an emergency room or urgent care center asGet to an emergency room or urgent care center as
quickly as possible. If possible, continue to flush your eyequickly as possible. If possible, continue to flush your eye
with clean water while you are waiting for an ambulancewith clean water while you are waiting for an ambulance
or traveling to the medical center.or traveling to the medical center.

70.  Cuts and ScratchesCuts and Scratches
 If you have a cut or scratch to your eyeball orIf you have a cut or scratch to your eyeball or
eyelid, you need urgent medical care. You mayeyelid, you need urgent medical care. You may
apply a cold compress while you wait forapply a cold compress while you wait for
medical treatment, but be careful nomedical treatment, but be careful no

71.  Large Foreign Objects Stuck in Your EyeLarge Foreign Objects Stuck in Your Eye
 Glass, metal, or objects that enter your eye at highGlass, metal, or objects that enter your eye at high
speed can cause serious damage. If something isspeed can cause serious damage. If something is
stuck in your eye, leave it where it is.stuck in your eye, leave it where it is.
 Do not touch it, do not apply pressure, and doDo not touch it, do not apply pressure, and do
not attempt to remove it. not attempt to remove it. This is a medicalThis is a medical
emergency and you should seek helpemergency and you should seek help
immediately. Try to move eye as little as possibleimmediately. Try to move eye as little as possible
while you wait for medical care .it may help to coverwhile you wait for medical care .it may help to cover
both eyes with a clean piece of cloth. This will reduceboth eyes with a clean piece of cloth. This will reduce
your eye movement until your doctor examines you.your eye movement until your doctor examines you.

72. 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 .