Ocular Emergencies

by
Dr Haania Khan
Definition Classification
An ocular emergency is a ● Sudden Loss of Vision
condition, occurrence of ● Sudden Spots in Front of
which is unpredictable and it Eyes
requires treatment or ● Double Vision
admission at short notice to ● Blood in Eye
avoid damage to the eye or ● Blunt Trauma
eyesight. ● Penetrating Injury
● Chemical Burn
● Infections
 Corneal Abrasions -scratch to the surface of cornea, AC is not entered
Symptoms and Signs: Sharp pain, photophobia, foreign body sensation, tearing,
discomfort with blinking. Epithelial defect that stains with fluorescein, absence of
underlying corneal opacification, injected conjunctiva, swollen lid

Work-Up
● Slit lamp examination: Use fluorescein dye, measure the size (e.g., height and
width) of the abrasion, and diagram its location. Evaluate for an AC reaction,
infiltrate corneal laceration, and penetrating trauma.
● Evert the eyelids to ensure that no foreign body is present, especially in the
presence of vertical or linear abrasions.
Treatment
● Antibiotic ;ointment or drops. Abrasions secondary to fingernails or vegetable
matter should be covered with a fluoroquinolone drop or ointment at least q.i.d.
● Contact lens wearer: Must have antipseudomonal coverage (i.e., fluoroquinolone).
May use antibiotic ointment or antibiotic drops at least q.i.d.
● Consider topical nonsteroidal anti-inflammatory drug (NSAID) drops for pain
control.
● Patching is rarely necessary and can actually cause a serious abrasion if not
applied properly.
● Follow up on next day for central or large corneal abrasion, or within 2-5 days to
confirm healing

,
Intraorbital Foreign Body
Symptoms and Signs

Decreased vision, pain, double vision, or may be asymptomatic. History of trauma.

Orbital foreign body identified by clinical examination, X ray, CT scan, orbital
ultrasound. A palpable orbital mass, limitation of ocular motility, proptosis, eyelid or
conjunctival laceration, erythema, edema, or ecchymosis of eyelids.

Work-Up

1. History: Determine the nature of the injury and the foreign body.

2. Complete ocular and periorbital examination with special attention to pupillary

reaction, IOP, and retinal evaluation. Carefully examine for an entry wound. Rule out
occult globe rupture. Gentle gonioscopy may be needed.
3. CT scan of the orbit and brain is always the initial study of choice.

4. B-scan

5. Culture any drainage sites or foreign material as appropriate.

Treatment

● NEVER remove an intraorbital foreign body at the slit lamp without first
obtaining
● Imaging to evaluate the depth and direction of penetration.
● Surgical exploration, irrigation, and extraction.
● Tetanus toxoid as indicated
● Administer systemic antibiotics promptly if the object is contaminated or organic,
treat as orbital cellulitis. Follow vision, degree (if any) of afferent pupillary defect,
extraocular motility,proptosis, and eye discomfort daily.
Chemical Burn
Signs and Symptoms: Pain, redness, photophobia, reduced vision, watering,
conjunctival hyperemia, corneal opacity

Must try to:

● Identify substance (acid vs base)

● Timeline of chemical exposure
● Irrigate for 15-30 mins
● Irrigate from medial to lateral
● If chemicals are involved use litmus paper to verify neutrality of chemicals
(normal ph reading 7.3- 7.7)
Management
● Adequate irrigation; copious but gentle irrigation using saline or Ringer lactate
solution.
● Antibiotic eyedrops
● Steroidal eyedrops
● Pupil dilating eye drops
● Vitamin c orally/ eye drops
Firework or Shrapnel/Bullet-Related Injuries
Symptoms: Ocular pain, decrease in vision, foreign body sensation, tearing, redness,
photophobia, history of trauma with firework, weapons of warfare, or devices that
result in high velocity impacts and shrapnel fragmentation (e.g., firecracker, sparkler,
firearm, explosive, grenade).

Signs: Foreign bodies, usually irregular in shape and fragmented in nature, embedded
in ocular or orbital tissues.

Work up:

1. History
 2. Visual acuity before any procedure is performed. One or two drops of topical
anesthetic may be necessary to facilitate the examination, but be careful not to cause
expulsion of ocular tissue if open globe exists. Also evaluate optic nerve function by
examining pupillary response and by testing color plates.

3. Examine for orbital signs: Paying particular attention to extraocular motility, globe
malposition, and sectoral chemosis/inflammation as this might help localize the
landing site of shrapnel or bullet material that has entered without exit.

5. Slit lamp examination: Locate and assess the depth of any foreign body. Examine
closely for possible entry sites (rule out self-sealing lacerations), pupil irregularities,
iris tears , capsular perforations, lens opacities, hyphema, AC shallowing (or deepening
in scleral perforations), and asymmetrically low IOP in the involved eye. Assess for any
damage to the lacrimal apparatus.
6. Dilate the eye and examine the posterior segment for a possible IOFB unless there is
risk of extrusion of intraocular contents.

7. Consider a B-scan ultrasonography, a CT scan of the orbit (axial, coronal, and

parasagittal views).

Treatment and Follow-Up

1. Depends on the specific injuries present. If foreign body is accessible then remove it
under magnification and after application of topical anesthetic.

2. Consider tetanus prophylaxis

3.. If foreign bodies are present but either inaccessible or associated with injuries that
prohibit safe removal at the slit lamp. The risk of iatrogenic optic neuropathy or
diplopia with attempted surgical removal of foreign bodies must be weighed against
the risk of delayed complications if left near vital orbital structures.
Infections (endophthalmitis)
Symptoms and Signs: Pain, redness, discharge, reduced vision, watering, photophobia,
red eye, irregular corneal surface, hypopyon(layering of white blood cells in the AC)

Management:

● Urgent Corneal scrapings for gram staining and eye swabs for culture and
sensitivity
● Antibiotic/antifungal eye drops
● Subconjunctival antibiotics
● Intravitreal antibiotics
● IV antibiotics
Uveitis
Signs and Symptoms: Pain, red eye, photophobia, reduced vision, dull headache,
hyperemia around the edge of cornea, small pupil, Irregular pupil

Treatment:

● Cycloplegic eye drops

● Steroidal eye drops
● Subconjunctival steroids
● Oral steroids
Sudden loss of vision (painless)
● Central Retinal Artery Occlusion
● Central Retinal Vein Occlusion
● Vitreous Hemorrhage
● Ischemic Optic Neuropathy
● Retinal Detachment
Central Retinal Artery Occlusion
Signs and symptoms: Unilateral, painless, acute vision loss (counting fingers to light
perception in 94%). Superficial opacification or whitening of the retina in the posterior
pole(pale optic disc), and a cherry-red spot in the center of the macula.

Work-Up

● ESR, CRP, and platelets

● Blood pressure.
● Fasting blood sugar and HBA1c,
● CBC with differential,
● PT/PTT).
● Lipid profile, antinuclear antibody (ANA), rheumatoid factor, syphilis testing ,
serum protein electrophoresis, hemoglobin electrophoresis.
● Carotid artery evaluation by duplex Doppler US.
● Cardiac evaluation with ECG, echocardiography, and
● Consider IVFA, OCT, and/or electroretinography (ERG) to confirm the diagnosis.

Treatment:

There is improvement after the following treatments, if instituted within 90 to 120

minutes of the occlusive event.

● Immediate ocular massage with fundus contact lens or digital massage.

● Anterior chamber paracentesis
● IOP reduction with acetazolamide
● Topical beta-blocker .
Follow-Up

Repeat eye examination in 1 to 4 weeks, checking for neovascularization of the

iris/disc/angle/retina (NVI/NVD/NVA/NVR), if neovascularization develops, perform
panretinal photocoagulation (PRP) and/or administer an anti-VEGF agent(Avastin).
Retinal Detachment
History of blunt trauma, rapid deceleration, high myopia, over 50 yrs old

Symptoms: painless flashes of light, curtain/shadow moving over field of view,

peripheral or central loss or both, new floaters

Signs: Elevation of the retina, vitreal hemorrhage

Work-Up

● Indirect ophthalmoscopy with scleral depression.

● Slit lamp examination
● B-scan
Treatment:

Patients with an acute RD that threatens the fovea should have surgical repair
performed urgently.

Surgical options include;

● Laser photocoagulation
● Cryotherapy
● Pneumatic retinopexy
● Vitrectomy (PPV, AV)
● scleral buckle.
Sudden loss of vision (painful)
● Acute Angle Closure Glaucoma
● Optic Neuritis
Acute Glaucoma (closed angle) Sudden onset of high Intraocular
pressure (IOP) caused by blockage of aqueous drainage
Symptoms: Pain, blurred vision, colored lights around lights, frontal headache, nausea
and vomiting

Signs: High IOP, clouded/misty cornea, red eye, fixed or mid-dilated pupil, pupil not
reactive to light.

Treatment:

● Do not dilate pupil.

● Compression gonioscopy is essential to determine if the trabecular blockage is
reversible and may break an acute attack.
● Pilocarpine eye drops
● Beta blocker eye drops (timolol) (codor z)
● IV mannitol
● IV acetazolamide (AZM)
● Surgical : Yag laser Iridotomy, Peripheral Iridotomy, Trabeculectomy
● Prophylactic Treatment to fellow eye

Follow-Up

After definitive treatment, patients are reevaluated in weeks to months initially, and
then less frequently.
Optic Neuritis
Signs and Symptoms:

Loss of vision over hours (rarely) to days. Usually unilateral, but may be bilateral.
Age 18 to 45 years. Orbital pain, especially with eye movement. Acquired loss
of color vision. Reduced perception of light intensity. May have other focal
neurologic symptoms (e.g., weakness, numbness, tingling in extremities). Relative
afferent pupillary defect (RAPD) in unilateral or asymmetric cases; decreased color
vision; central, cecocentral, arcuate, or altitudinal visual field defects.
Work-Up

1. History: Complete ophthalmic and neurologic examinations, including pupillary and

color vision assessment, evaluation for vitreous cells, and dilated retinal examination
with attention to the optic nerve.

3. MRI of the brain and orbits .

4. Check blood pressure.

5. Visual field test

6. Consider the following: CBC, ESR, ACE level, Lyme antibody, FTA-ABS or
treponemal specific assay and RPR or VDRL tests, and chest x-ray or CT.
Treatment:

● If MRI reveals at least one typical area of demyelination, offer pulsed intravenous
steroid in the following regimen within 14 days of decreased vision:
● Methylprednisolone 1 g/day i.v. for 3 days, then
● Prednisolone (deltacortril) 1 mg/kg/day p.o. for 11 days, then
● Taper prednisolone over 4 days (20 mg on day 1, 10 mg on days 2 through 4).
● Antiulcer medication for gastric prophylaxis.(risek, nexium)
Hyphema
Symptoms and Signs: Pain, blurred vision, history of blunt trauma. Blood or clot or
both in the AC, usually visible without a slit lamp.

Work-Up

1. History: Mechanism of injury? Protective eyewear? Time of injury? Time and extent
of visual loss? Use of medications with anticoagulant properties. Personal or family
history of sickle cell disease or trait. Symptoms of coagulopathy.

2. Ocular examination: First rule out a ruptured globe Evaluate for other traumatic
injuries. Document the extent (e.g., measure the hyphema height) and location of any
clot and blood. Measure the IOP. Perform a dilated retinal evaluation without scleral
depression. Consider a gentle B-scan ultrasound if the view of the fundus is poor.
3. Consider a CT scan of the orbits and brain (axial, coronal, and parasagittal views,
1-mm sections through the orbits) when indicated (e.g., suspected orbital fracture or
IOFB, loss of consciousness).

Treatment:

● Confine to bed rest .Elevate the head of bed to allow blood to settle. Discourage
strenuous activity, bending, or heavy lifting.
● Place a rigid shield (metal or clear plastic) over the involved eye at all times. Do
not patch because this prevents recognition of sudden visual change in the event
of a rebleed.
● Cycloplege the affected eye (mydriacyl-tropicamide)
● Avoid antiplatelet/anticoagulant medications unless otherwise medically
necessary.
● Mild analgesics only. Avoid sedatives.
● Topical steroids
Thank you.