OCULAR EMERGENCY
MS.HEBSIBA P
ASSOCIATE PROFESSOR, DEPT.OF MEDICAL SURGICAL NURSING, SGNC
OUTLINE
• Introduction
• Definition
• Classification
• Signs and symptoms
• Triage
-history
-physical examination
• Diagnosis and management of common ocular
emergency
4/3/2020 MS.HEBSIBA P, ASSOCIATE PROFESSOR, DEPT. OF MEDICAL SURGICAL NURSING
Introduction
• Prompt recognition and appropriate
treatment of ocular emergencies are
essential in the primary care setting
when the outcome may depend on time.
• All ocular emergencies should be
referred immediately to the emergency
department or an ophthalmologist.
• Careful eye examination and simple tests
can help primary care physicians make
decisions about appropriate treatment
and referral
4/3/2020 MS.HEBSIBA P, ASSOCIATE PROFESSOR, DEPT. OF MEDICAL SURGICAL NURSING
Definition
• Ocular Emergency;-
Are ocular condition that needs
quick identification and hence quick
management to save the patient from
further pathologies.
;- It may involve cuts, scratches, objects
in the eye, burns, chemical exposure,
and blunt injuries to the eye or eyelid
e.t.c
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
CLASSIFICATION
1.according to etiology
2.according to urgent workup
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Ocular Emergencies
Trauma
Non-Trauma
Penetrating Blunt Neuro-
Eye
ophthalmology
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
FUTHER CLASSIFICATION
1.IMMEDIATE- within minutes
a)chemical burns
b)central retinal artery occlusion
c)orbital hemorrage
2.VERY URGENT-within few hours
a) Endophthalmitis
b) cavernous sinus thrombosis
c) Microbial Keratitis
d) Orbital Cellulitis
e) Acute Glaucoma
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Classification cont…
3.URGENT-within 1day
a) Hyphema
b) lid laceration
c) corneal abrasion
d)orbital fracture
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Ocular Emergencies
Ocular conditions requiring immediate
treatment
• Acute Angle-Closure Glaucoma
• Central Retinal Artery Occlusion
• Orbital Cellulitis
• Cavernous Sinus Thrombosis
• Endophthalmitis
• Retinal Detachment
• Toxic Causes of blindness
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Nontraumatic Occular Emergencies
Acute Dacryocystitis Acute hydrops of the
Acute Dacryoadenitis cornea
Acute Hordeolum Hyphema Uveitis
Preseptal cellulitis (iritis & iridocyclitis)
Spontaneous Vitreous hemorrhage
subconjunctival
hemorrhage Retinal hemorrhage
Conjunctivitis Central retinal vein
Bacterial corneal ulcer occlusion
Viral keratoconjunctivitis Optic neuritis
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Ocular burns and trauma
Ocular Burn 1. Ecchymosis of the Eyelids
• Alkali Burns
2. Lacerations of the Eyelids
• Acid Burns
3. Orbital hemorrhage
• Thermal Burns
• Burns Due to Ultraviolet
4. Fracture of the Ethmoid bone
Radiation 5. Blowout Fractures of the Floor of
Mechanical Trauma to the Eye the Orbit
Penetrating or Perforating 6. Corneal Abrasions
injuries
Blunt Trauma to the Eye, 7. Corneal & Conjunctival Foreign
Adnexa,& Orbit Bodies
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
General signs and symptoms
• Bleeding or other discharge from or around the eye
• Bruising
• Decreased vision
• Double vision
• Eye pain
• Headache
• Itchy eyes
• Loss of vision,
• total or partial, one eye or both Pupils of unequal size
• Redness -- bloodshot appearance
• Sensation of something in the eye
• Sensitivity to light
• burning in the eye MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
History
It MUST BE THERE but the format depends on that emergent
condition
• A detailed or comprehensive history is warranted to identify
emergent situations.
• An ophthalmologist should be summoned immediately when the
patient has obvious eye trauma; The history and exam can be
completed in the meantime.
• In a chemical exposure trauma, however, immediate eye
irrigation is mandatory.
• Initial questioning should focus on determining whether the
problem is traumatic, inflammatory or neurovascular.
• The technician should ask about prior surgeries or contact lens
use, which may be helpful in determining infectious causes. The
medical, family and social histories can suggest risk factors for
inflammatory or neurovascular etiologies. Query current and
recent medications to determine if antibiotics or topical steroids
suggest an infectious etiology.
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
History..
• Although it may be difficult to determine which symptoms
threaten vision and require emergent care, a careful patient
history may uncover several important symptoms. These
include reduced visual acuity; visual field changes; floaters;
photopsia; head, orbital or ocular pain; changed appearance
of the ocular adnexa; ptosis; diplopia and alterations in pupil
size. If the symptoms are severe or rapidly progressive,
urgent referral to an ophthalmologist is appropriate.
Past ophthalmic and general medical history provide
background for the current symptoms. It is important to
determine whether the current condition could be a
recurrence or a complication of a previous ophthalmic
condition. Always ask about any recent ophthalmic or orbital
surgery.
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Examination
Depends on situation
• Quick physical examination
• Emergent TEST
-VA
-RETINOSCOPY
- FUNDOSCOPY
-CT SCAN
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Diagnosis and management of
common occular emergency
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Chemical burn
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.
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Chemical Burn
Treatment should be instituted
IMMEDIATELY, even before talking
history
Emergency Treatment:
Saline Copious irrigation (until neutral
pH i.e 7.3-7.7):, may range from a few
liters to many liters (more than 8 to 10 L
Lids should be retracted and
fornices swabbed for particulate Tap water
matter
Once pH is stabilized
Cycloplegic agent
4/3/2020
Broad-spectrum MS.HEBSIBA P, ASSOCIATE PROFESSOR,
antibiotic DEPT. OF MEDICAL SURGICAL NURSING
Lid laceration
Eyelids don’t have fat
Take care check lid margin
Orbital fat usually protrudes through
septal lacerations
Fat in the lid laceration confirms the
diagnosis
High incidence of globe penetration
and intraocular foreign bodies
High risk for orbital cellulitis Medial injuries may affect lacrimal
passages
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Management of Lid Lacerations
R/O associated ocular injury
Remove superficial FB
Rule out deeper FB
laceration repair
Give tetanus prophylaxis
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Corneal FB
Often metallic foreign body following
work injury
foreign body sensation, tearing, red,
or painful eye.
Remove foreign body
Evert the eyelid to rule
out additional FB Linear epithelial defects suggestive of foreign
Topical
4/3/2020 AB MS.HEBSIBA P, ASSOCIATE PROFESSOR, body under the eye lid
DEPT. OF MEDICAL SURGICAL NURSING
Treatment:
Periorbital Cellulitis (Preseptal Cellulitis)
Hospital
Warm, indurated, erythematous eyelids only
admission for
IV Cefuroxime
Orbital Cellulitis (Postseptal Cellulitis)
Warm, indurated, erythematous eyelids
only
emergent orbital and sinus CT
Fever, toxicity, proptosis,
painful ocular motility,
limited ocular excursion
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Retrobulbar hematoma
APD,
Acute orbital compartment syndrome 2°
to blunt or penetrating trauma Proptosis
Hemorrhage into closed space of orbit Ophthalmoplegia
Diminished vision
IOP leading to vision loss from optic
nerve damage / retinal ischemia IOP
Immediate lateral canthotomy and cantholysis
indicated if IOP > 40mmHg or vision loss
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Acute Angle Closure Glaucoma (AACG) -
Pain (sever brusting ) Conjunctival injection
(ciliary flush)
Halos (around lights)
Corneal edema
Nausea/vomiting
Mid-dilated, fixed pupil
Medical Tx IOP ( stony hard)
Reduce production of aqueous humor
Topical -blocker (timolol 0.5% - 1- 2 gtt)
Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po)
Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min)
Or increase outflow
Topical -agonist (phenylephrine 1 gtt)
Miotics (pilocarpine 1-2%)
Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then Q1H
Definitive Tx
Laser peripheral iridectomy MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
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
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Penetrating / Ruptured Globe
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
Penetrating / Ruptured Globe : Management
Stop examination
Shield the eye (do not patch)
Give tetanus prophylaxis
Give systemic antibiotics
Do not apply eye ointment or eye drop
Film orbit if IOFB can’t be R/O
Refer immediately to ophthalmologist
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
THE END
THANK YOU
MS.HEBSIBA P, ASSOCIATE PROFESSOR,
4/3/2020
DEPT. OF MEDICAL SURGICAL NURSING
