Ocular Emergencies

Pisit Preechawat, MD
Department of Ophthalmology, Ramathibodi Hospital

Ocular Anatomy

Bony Components of Orbit

1

1.1. Frontal
Frontal

bone
bone

2.2. Zygomatic
Zygomatic bone
bone
3.3. Maxillary
Maxillary bone
bone
4

4.4. Sphenoid
Sphenoid bone
bone

7
6

5.5. Ethmoid
Ethmoid bone
bone
3

6.6. Lacrimal
Lacrimal bone
bone
7.7. Palatine
Palatine

Size 30 x 40 x 45 mm

bone
bone

Paranasal Sinus

Ocular Anatomy

Orbicularis Oculi

Ocular Anatomy

Ocular Anatomy

Ocular Anatomy

Extraocular Muscles

Optic Nerve

Venous System

Ocular Emergencies
Blunt trauma
Trauma
Penetrating trauma
Non - trauma

Acute Eye Conditions

Emergency
( Immediately )

Retinal arterial
occlusion
Chemical burns

Very Urgent
( Within a few hours )

Urgent
( Within one day )

Perforation

Orbital cellulitis

Ruptured

Orbital injury

Acute glaucoma

Corneal ulcer

Sudden congestion

Corneal abrasion

proptosis

Hyphema
Intraocular FB
Retinal detachment
Macular edema

Nontraumatic Ocular Emergencies

Acute Dacryocystitis

Ocular Emergencies

Acute Dacryoadenitis
Acute Hordeolum
Preseptal cellulitis
Spontaneous subconjunctival hemorrhage

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

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 burns and trauma

Ocular Burn
Alkali Burns

Ocular Emergencies

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

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

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

Fundus Examination
A dilated pupil makes it easier to see the optic
nerve, macula, and retina
- 1% tropicamide ( Mydriacyl )
- 2.5% phenylephrine ( Neo-Synephrine )

PanOptic
Ophthalmoscope

Indirect
Ophthalmoscope

Intraocular Pressure Measurement

Digital palpation
Schiotz tonometer

Ocular Trauma
Closed Globe
Burn

Laceration

Open Globe
Rupture

Laceration

Contusion
Penetrating

Perforating

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

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

Corneal Abrasion : Management

Searching for conjunctival foreign body

Topical cycloplegia, ATB ointment

Pressure patching for 24 hours
Dont apply PP if there is a
significant risk of infection.

Corneal Ulcer

Hypopyon

No patching
Topical antibiotics
Ophthalmologist referral

Eye Shield

Conjunctival Foreign Bodies

Corneal Foreign Bodies

Rust ring
Corneal foreign body with rust ring

Corneal Foreign Bodies

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 Body Removal

Traumatic Hyphema

Disruption of blood vessels in the iris or ciliary body

Blood in anterior chamber

Traumatic Hyphema : Classification

Grade

Size of Hyphema

No layered blood
circulating red blood cells only

Less than 1/3

II

1/3 to 1/2

III

1/2 to less than total

IV

Total

Traumatic Hyphema

Traumatic Hyphema : Management

Elevate the patients 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

Rebleeding can occur 3 to 5 days later in 30%
Uncontrolled glaucoma or blood stained cornea
requires anterior chamber wash out

Lid Lacerations

Sharp or blunt trauma

R/O associated ocular injury
Remove superficial FB
Rule out deeper FB
Give tetanus prophylaxis

Full Thickness Lid Lacerations

Tear lid margin

- Gray line
- Lash line
- Mucocutaneous junction

Lid Margin Repair

Laceration of lower eyelid margin

Post-operative result following a

primary repair

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

Lid Lacerations with tear canaliculi

Canalicular Repair

Tear Canthal Tendon

Woman with tearing and medial canthal

asymmetry after the repair of a laceration
sustained during a domestic assault

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

Irregular pupil

Penetrating / Ruptured Globe

Penetrating / Ruptured Globe

Ruptured globe caused by golf ball

Penetrating / Ruptured Globe : Management

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 cant be R/O
Refer immediately to ophthalmologist

Intraocular or Intraorbital Foreign Bodies

Ocular Trauma

Traumatic cataract

Traumatic mydriasis

Traumatic lens subluxation

Traumatic lens subluxation

Chemical Ocular Injury

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 : Management

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

Irrigation in case of chemical injury

Chemical Ocular Injury : Management

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
No corneal involvement
- ATB + steroid eye drop
Ophthalmologists Referral

Chemical Ocular Injury : Classification

Grade I

Grade II

Grade III

Grade IV

Chemical Ocular Injury : Management

Preservative-free artificial tears
Topical non-preserved steroid
Topical cycloplegic
Topical antibiotics
Oral analgesics
Pressure patch or bandage CL
Antiglaucoma +

Chemical Ocular Injury

Bilateral Alkali Injuries

Chemical Ocular Injury : Management

Keratoprosthesis

Corneal Transplantation

Cyanoacrylate Glue
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
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.

Non-traumatic Ocular Emergencies

A 55-year-old woman with a red eye, blurred

vision with halos, nausea, and vomiting

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

VA - HM
Conjunctival injection
Hazy cornea
Shallow anterior chamber
Fixed mid-dilated pupil
IOP 56 mmHg

Acute Angle Closure Glaucoma

Anterior Chamber Depth

Acute Angle Closure Glaucoma

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

A 60-year-old woman with acute, painless loss of

vision in the right eye

Central Retinal Artery Occlusion

Visual acuity CF LP in 90% of cases
Opaque white retina and attenuated vessels

Central Retinal Artery Occlusion

Treatment must be initiated immediately.
Ocular massage
Inhaled carbogen ( 95% O2 and 5% CO2 )
Reduced intraocular pressure
Consult ophthalmologist immediately
Anterior chamber paracentesis
Direct infusion of t-PA or urokinase in the
ophthalmic artery

A 40-year-old man with left eyelid edema and pain

( worse on eye movement )

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

Orbital Cellulitis
Broad spectrum intravenous antibiotics
CT scan orbit
Ophthalmology & ENT consultation

Subperiosteal abscess

Preseptal Cellulitis

Endophthalmitis

Urgent Neuro-ophthalmology

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

A 55-year-old man with HT and acute visual loss in RE

VA 20/100, 20/20

RAPD +ve RE

ESR 10 mm/hr
Nonarteritic anterior ischemic optic neuropathy

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

Arteritic anterior ischemic optic neuropathy

ESR 94 mm/hr, high level of C - reactive protein

Pathology : Giant Cell ( Temporal ) Arteritis

A 35-year-old man with left painful third nerve palsy

VA 20/25, 20/30
Dilated, nonreactive pupil LE

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 %

A 35-year-old man with a suspicious of aneurysmal

third nerve palsy

A 40-year-old woman with sudden onset of left

third nerve palsy, visual loss and severe headache
VA 20/30, LP

+ve RAPD LE

What is the diagnosis?

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 preexisting pituitary mass

A 17-year-old man with right blured vision after

minor blunt trauma.
VA 20/32, 20/20 + ve RAPD RE
Normal fundi
LE

RE

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

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

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

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

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 .