1. The document discusses various ocular emergencies including traumatic injuries like hyphema, ruptured globe, and chemical burns as well as non-traumatic emergencies like acute angle closure glaucoma and orbital cellulitis. 2. Management strategies are provided for different conditions including irrigation for chemical burns, medications to lower IOP for glaucoma, and IV antibiotics for orbital cellulitis. 3. Immediate referral to an ophthalmologist is recommended for penetrating injuries, ruptured globe, retinal artery occlusion, and conditions requiring surgery.

1. Ocular Emergencies Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital

2. Ocular Anatomy

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. Paranasal Sinus

5. Ocular Anatomy Orbicularis Oculi

6. Ocular Anatomy

7. Ocular Anatomy

8. Ocular Anatomy

9. Extraocular Muscles

10. Optic Nerve

11. Venous System

12. Ocular Emergencies Trauma Non - trauma Blunt trauma Penetrating trauma

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. 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. 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. Eye Examination Visual acuity External Eye : orbit, periorbital skin, eyelids Confrontation visual fields Ocular motility

17. Anterior Segment Conjunctiva Cornea Anterior chamber Iris Lens Pupils : RAPD Eye Examination

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. Digital palpation Schiotz tonometer Intraocular Pressure Measurement

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

21. Causes Trauma, Hypertension Valsava pressure spikes Spontaneous No treatment Resolve within 2 weeks Subconjunctival Hemorrhage

22. Pain , photophobia , FB sensation, tearing Conjunctival injection, swollen eyelid Corneal Abrasion Epithelial staining defect with fluorescein

23. 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 Abrasion : Management

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

25. Conjunctival Foreign Bodies

26. Corneal foreign body with rust ring Rust ring Corneal Foreign Bodies

27. 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 Bodies

28. Corneal Foreign Body Removal

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

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. Traumatic Hyphema

32. 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 : Management

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

34. Sharp or blunt trauma R/O associated ocular injury Remove superficial FB Rule out deeper FB Give tetanus prophylaxis Lid Lacerations

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

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

37. Refer to ophthalmologist if there are associated ocular injuries Lid Lacerations Ruptured globe Lacrimal drainage system Levator aponeurosis Medial canthal tendon Tissue loss ( > 1/3 )

38. Lid Lacerations with tear canaliculi

39. Canalicular Repair

40. Woman with tearing and medial canthal asymmetry after the repair of a laceration sustained during a domestic assault Tear Canthal Tendon

41. Penetrating / Ruptured Globe Corneal or scleral lacerations Hypotony (not always present) Severe chemosis & hemorrhage Intraocular contents may be outside the globe Limitation of extraocular motility Shallow anterior chamber Irregular pupil

42. Irregular pupil

43. Penetrating / Ruptured Globe

44. Ruptured globe caused by golf ball Penetrating / Ruptured Globe

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

46. Intraocular or Intraorbital Foreign Bodies

47. Ocular Trauma Traumatic cataract Traumatic mydriasis Traumatic lens subluxation Traumatic lens subluxation

48. 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 Injury

49. 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 : Management

50. Irrigation in case of chemical injury

51. 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 : Management Ophthalmologists Referral No corneal involvement - ATB + steroid eye drop

52. Chemical Ocular Injury : Classification Grade I Grade II Grade III Grade IV

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

54. Bilateral Alkali Injuries Chemical Ocular Injury

55. Chemical Ocular Injury : Management Corneal Transplantation Keratoprosthesis

56. 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 Glue

57. 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 Glue

58. Non-traumatic Ocular Emergencies

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. 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. Anterior Chamber Depth

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

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

67. Broad spectrum intravenous antibiotics CT scan orbit Ophthalmology & ENT consultation Orbital Cellulitis Subperiosteal abscess

68. Preseptal Cellulitis

69. Endophthalmitis

70. Urgent Neuro-ophthalmology

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. 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. 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. Pathology : Giant Cell ( Temporal ) Arteritis

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

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. A 35-year-old man with a suspicious of aneurysmal third nerve palsy

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. 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. 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. 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. 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. 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. 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. 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. Thank you for your attention