This comprehensive overview of common ophthalmological presentations that ED registrars may encounter has been kindly shared by Dr Andrew White BMedSci(hons) MBBS PhD FRANZCO, Consultant Ophthalmologist, Westmead Hospital & Sydney Medical School (USyd)

1. Eye Emergencies
Dr Andrew White
BMedSci(hons) MBBS PhD FRANZCO
Clinical Senior Lecturer
Discipline of Ophthalmology and Eye Health
Glaucoma Specialist, Westmead Hospital

2. A Useful Resource
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0013/155011/eye_manual.pdf

3. Anatomy

4. Anatomy

5. The Basic Eye Exam

6. • You can learn a lot from pinhole acuity!
• Better with pinhole: refractive/anterior
segment problem
• Not better: posterior segment problem
• Dilate (Tropicamide)! The risk of angle
closure is tiny and you are in a hospital!

7. • Pupil exam will tell you a lot.
• Look for RAPD
– Optic nerve problem
• Look for sluggish pupil
– Uveitis
– Angle closure glaucoma

8. Common Benign Things
• Pingueculum
• Pterygium
• Trabeculectomy bleb

9. Lids

10. Chalazion
• Often a child but also
young adults
• Small lump on the upper
or lower lid with some
swelling
• Usually sent in by LMO
as periorbital cellulitis but
rarely is
• Treated by warm
compresses and chlorsig
• Often spontaneously
discharges

11. Periorbital and Orbital Cellulitis
• Usually in young children who
are fairly well
• May start from a small scratch
or chalazion
• Usually a 48hr trial of oral
antibiotics before moving to IV
if needed
• Don’t need to do a CT straight
off
• Children with orbital cellulitis
look sick.
• CT will show full sinuses and
ENT need to be involved to
drain it +IV antibiotics

12. Dacryocystitis
• Usually a young to middle
aged adult with localised
cellulitis over the lacrimal
sac and a fever
• Needs IV antibiotics and
warm compresses
• A pimple may form that
will discharge
spontaneously or can be
incised by eye team

13. Lid Trauma
• We are more concerned
about medial canthus
injuries than lateral
canthus due to location of
lacrimal system
• Lid margin injuries need
specialised repair
• Make sure the eye and
orbit are intact

14. Cornea

15. Corneal Abrasion
• Commonly from a finger
in the eye
• Very painful
• Treat with chlorsig and a
double firm pad
• QID chlorsig drops 7 days
• Intensive chlorsig is
totally useless
• Look under the lids for
tarsal foreign body!
• Can lead to recurrent
erosions

16. Corneal Foreign Body
• Typically from angle
grinding or small piece of
wood
• Usually can be lifted off
with a cotton bud or
25/23G needle
• Rust ring can be removed
later in clinic
• Chlorsig QID 1 week

17. Subconjunctival Haemorrhage
• Looks worse than it is
• Trivial
• Idiopathic
• Not related to INR.
Sometimes high BP
• Will get better in 2
weeks
• May need lubricants
for comfort

18. Conjunctiva

19. Bacterial Conjunctivitis
• Unilateral
• Mucous discharge
• ?Previous foreign
body
• Swab the discharge
and give chlorsig 7
days
• Clinic f/u if no better

20. Viral Conjunctivitis
• Fairly common and goes in runs
• Characterised by watery discharge and
itch
• 2 main forms:
• Adenoviral
• Herpes (simplex and zoster)

21. Adenoviral Conjunctivitis
• Probably the most contagious
thing on the planet
• Wash everything after contact!!!
• Often an flu like prodrome
• Accompanied by chemosis and lid
swelling
• Characterised by conjunctival
follicles
• Typically goes from one eye to the
next over a few days
• Self limiting but can persist for 2-3
weeks.
• Patient is contagious for 2 weeks
• Lubricants and cool compresses
help

22. Herpes Conjunctivitis
• Either HSV 1, 2 or Zoster
• Unilateral
• Usually fairly mild
symptoms
• May be accompanied by
a dendritic ulcer
• Treatment is zovirax
ointment 5x a day 10
days
• Check the retina!

23. Herpes Zoster Ophthalmicus
• Only possible if the V1 division
is involved.
• Usually only a mild
conjunctivitis is involved
treated with lubricants and cool
compresses
• There may be some corneal
ulceration
• Main concern is retinal
involvement – check!
• Treatment is systemic oral
antivirals (acyclovir. Valtrex
etc).
• Trigeminal neuralgia may be a
long term problem

24. Allergic Conjunctivitis
• Can be seasonal, drugs or
contact
• Frequently bilateral but can be
unilateral with mild lid swelling
• History is usually the giveaway
• Papillae under the lids
• Remove the stimulus, lubricate
• Call us if contemplating
steroids
• DO NOT GIVE STERIODS
INDEPENDENTLY
• There are a number of over
the counter topical
antihistamines (eg Lomide,
Zatiden)

25. Inflammatory Conditions

26. Uveitis
• Essentially an arthritis of the eye
• Usually young, unilateral red eye
with photophobia
• Flare and cells in the anterior
chamber +/- hypopion and
irregular sluggish pupil
• May be HLAB27 +ve (ankylosing
spondylitis)
• Other causes: Drugs, HSV,
Syphilis, Sarcoid, TB, Bartonella,
Lyme disease, LYMPHOMA –
beware the elderly patient
• Treated with dilating drops and
intensive topical steroids (by
ophthalmology)

27. Scleritis and Episcleritis
• Episcleritis: Young, localised
area of redness over the
conjunctiva that blanches with
phenylephrine 2.5%
• Self limiting. Gets better with
NSIADS and weak topical
steroids
• Scleritis: Old, rheumatoid
patients but also seen in
infections like syphilis
• Redness does not blanch
• Extremely painful.
• Treated with oral steroids and
NSAIDS
• Risk of perforation

28. Blinding Conditions

29. Contact Lens Keratitis
• Painful, rapidly
progressive
• Almost always
pseudomonas
• Characterised by white
corneal infiltrates
• Can progress to
blindness in 24hrs
• Needs intensive ciloxan
eye drops (hourly)
• Chlorsig will do nothing!

30. Chemical Burns
• Acid and chemical burns
will damage superficial
cornea then stop
• Alkali burns will continue
to penetrate until
neutralised
• Blindness results not only
from initial damage but
limbal stem cell failure
• Irrigate, irrigate, irrigate!
ASAP
• Check pH of all chemical
injuries at presentation
and after irrigation

31. Endophthalmitis
• Will be surgical or endogenous
• Surgical typically presents day
1-7 post surgery with a rapidly
progressive history of pain and
redness (it is rare to present
months to years later but it
does happen)
• Endogenous is found in the
immunosuppressed, moribund
and IV drug users
• Blindness is rapid if untreated
(hours)
• Needs a vitreous tap and
intravitreal
antibiotics/antifungals/antivirals
as determined by
ophthalmology

32. Acute Glaucoma
• Will be open or closed angle
• Open angle usually has a long
history of glaucoma and a
slowly progressive history
• Angle closure glaucoma is
typically an elderly, dark iris
patient who presents at night
(when the eye dilates)
• Acute glaucoma is unilateral,
painful, often accompanied by
nausea
• The iris is usually stuck to the
cornea and the eye will feel
relatively firm
• The pupil will not react

33. Sudden Painless Loss of Vision

34. Optic Neuritis
• Typically young sudden loss of vision
accompanied by pain on eye movement
• May or may not have a background of MS
• Will have a RAPD
• Otherwise normal exam though there may be
swelling of the optic disc
• There is no role for oral steroids
• IV methylprednisone shortens the duration of the
attack but not the severity or risk of recurrence
• Needs MRI to look for plaques

35. Ischemic Optic Neuritis
• Will be arteritic or non
arteritic
• May or may not have
optic disc swelling
• Check ESR and CRP as
GCA symptoms are
vague and GCA patients
tend to be poor historians
• Carotid dopplers need to
be done via LMO

36. Central Retinal Vein Occlusion
• Typically large hypertensive
50+ year old women
• Dilated exam reveals
widespread haemorrhage and
swelling (chronic diabetics look
the same but the vision loss is
not acute)
• Can be ischemic or non
ischemic
• May progress to
neovascularisation and
rubeosis if untreated (the 100
day glaucoma) so followup is
important

37. Central Retinal Artery Occlusion
• Presents with a very
pale retina (look at
the other side) and
you may or may not
see an embolus
• Needs aggressive
IOP lowering if
presents within 6 hrs
but patients rarely do
• Needs carotid
dopplers via LMO

38. Wet ARMD
• Usually an elderly
patient with known
ARMD with sudden
loss of central vision
• Needs f/u for
intravitreal Lucentis
(rooms)

39. Retinal Detachment
• Usually presents with a
few days of
flashes/floaters then a
slowly progressive
shadow or cobweb in 1
eye that doesn’t move or
go away
• Usually sent in by
optometrists who may be
wrong
• Needs VR review/repair

40. Vitreous Haemorrhage
• Often confused with
detachment as symptoms
are similar
• May be a known diabetic
who bleeds from
neovascularisation or a
traumatic vitreous
detachement
• You won’t be able to see
the retina on dilated exam
and neither will we.
• Needs f/u for a B scan
U/S to ensure no
detachment

41. Hyphema
• Typically a history of blunt
trauma to the eye and
sudden loss of vision
• The AC may be cloudy
before a blood level
settles in the AC
(microhyphema)
• IOP is usually low but can
go high
• Needs dilating drops,
topical steroids and strict
bed rest

42. Orbital fractures
• Usually from an assault or
sports injury
• Usually medial wall or floor
• Needs CT to check for globe
rupture
• True entrapment of rectus
muscles is rare, usually in
young teens and they will
vomit/be unwell
• They need oral antibiotics and
are not to blow nose
• Maxfax/plastics need to be
involved.
• If acuity is OK, eye review can
be within the week as an
outpatient

43. Major Blunt Trauma
• MVAs etc
• High
impact/deceleration
injuries can shear the
optic nerve
• The patients are
usually intubated

44. Perforating Eye Injury
• Something flies into the eye at
high speed
• Vision is down
• Pupil will look irregular and will
point towards the perforation
• Leave the eye alone
• No pressure on the eye
• Give ADT and an IV
cephalosporin
• Get whatever imaging you can
for intraocular foreign body
(CT is best)
• Keep NBM

45. Ruptured Globe
• Occurs in high speed
MVAs and assaults
involving bats and
crowbars
• Fists are not usually
enough
• Lids may be so swollen
the eye can’t open – get a
CT
• No pressure on the eye,
ADT and an IV
cephalosporin
• Keep NBM