OPHTHALMOLOGY:

Ocular Emergencies

Lecturer: Roudel C. Rebong, MD

Transcriber: Patrick Angelo R. Bautista October 2019

Table of Contents Basic Information – History

I.Presentations of Ocular Emergencies 1 • Demographic data • Duration and tempo
II.
Ocular Emergencies 1 • Chief complaint • Associated s/sx
o True Emergencies 1 • Evolution of illness • Medical/ Surgical History
o Urgent Conditions 1 • Laterality • Medications/ Allergy
o Semi-urgent Conditions 1
III. True Ocular Emergencies 2 Questions to ask
1. Arterial Occlusive Disease 2 • Is the visual loss transient or persistent?
2. Chemical Burns 2 • Is the visual loss monocular or binocular?
IV. Urgent Conditions/ Acute Red Eye 2 • What was the tempo? Did the visual loss occur abruptly, or did it
1. Acute Angle Closure Glaucoma 2 develop over hours, days, or weeks?
2. Endophthalmitis 3 • What are the patients’ age and medical condition?
V. Acute Orbital Disease 3 • Did the patient have documented normal vision in the past?
1. Orbital Cellulitis 3
VI. Acute White Eye 3 Examination Protocols
1. Rhegmatogenous Retinal Detachment 3
2. Optic Neuritis 3 5-Point Examination
• Gross Examination • IOP determination
3. Retinoblastoma 3
4. Retinopathy of Prematurity 4 • Visual Acuity Testing • Fundoscopy
VII. Ocular Trauma 4 • EOM Evaluation
1. Blunt Trauma 5
2. Contusion Hematoma/ Traumatic Iritis/ Black Eye 5 Extended Visual Exam
3. Injuries to the Globe: Conjunctiva 5 • Visual Acuity Testing • Pupillary reflexes
4. Injuries to the Globe: Sclera 5 • Confrontation VF Test • Anterior Chamber Assessment
5. Injuries to the Globe: Cornea 5 • Periorbital & Gross • Fundoscopy
6. Injuries to the Globe: Iris 6 • EOM Evaluation • IOP determination
7. Injuries to the Globe: Lens 6
8. Injuries to the Globe: Posterior Pole 6 Instrumentation

9. Eyelid Thermal Burns 6

10. Lid Lacerations 6
11. Isolated Blow-Out/ Orbital Floor Fractures 6
VIII. Samplex n/a

Relevance
• The primary care physician needs to recognize conditions afflicting
or observable in the eye in order to make urgent referrals to
ophthalmologists and/or initiate therapy, whenever appropriate.
II. OCULAR EMERGENCIES
Objectives

• Be able to evaluate and handle a patient complaining of ocular

True Emergencies
related conditions potentially requiring immediate attention • Must address the condition within minutes
• To learn pertinent questions to ask 1. Chemical burns of the Globe
• To utilize the appropriate examination techniques 2. Central Retinal Occlusion
• To recognize conditions requiring immediate attention

Urgent Conditions
• Must address the condition within one to several hours
For what do Px consult their doctors urgently with regards to their eyes?
1. Acute Angle Closure Glaucoma
• Red and painful eye
2. Endophthalmitis
o Red eye differential, Ocular trauma 3. Penetrating Injuries of the Globe
• Urgent white eye

o Sudden asymptomatic visual loss, Leukocoria Semi-urgent Conditions
• Must address within days (whenever possible or even weeks)
I. PRESENTATIONS OF OCULAR EMERGENCIES 1. Acute exophthalmos

The Acute Red Eye 2. Retinal detachment endangering the macula

3. Blow-out fracture of the orbit
• Infections • Trauma
4. Optic Neuritis
• Inflammation • Blunt
5. Ocular tumors - Retinoblastoma
• Glaucoma • Penetrating/ Perforating



The Acute White Eye

• Acute visual loss • Intraocular tumor
• Vascular occlusion • Retinoblastoma
• Retinal detachment • Retinopathy of Prematurity
• Optic neuritis

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III. TRUE OCULAR EMERGENCIES IV. URGENT CONDITIONS IN OCULAR EMERGENCIES/ ACUTE RED EYE

1. Arterial Occlusive Disease 1. Acute Angle Closure Glaucoma

• " Chief Pathologic Feature: Elevation IOP is a consequence of

obstruction of aqueous outflow by occlusion of the trabecular

meshwork by the peripheral iris.
• $Iris is touching the cornea

[Acute Angle Closure Glaucoma] Presentation
Central Retinal Artery Occlusion Branch Retinal Artery Occlusion • Sudden unilateral eye pain
• occurs when flow of blood • occurs when one of the • With ipsilateral headache + vomiting
through the central retinal artery branches of central retinal • History of iridescent vision
is blocked artery becomes occluded o Iridescent – showing luminous colors that seem to change when
• " widespread retinal whitening • " sectoral retinal whitening seen from different angles
with a cherry red spot • Blurring of vision
• Red eye
Common Presentation • Hazy cornea
• Overall pallor of the involved area/s of the retina • Mid-dilated, sluggish to non-reactive pupil
• Shallow anterior chamber
Central Retinal Artery Occlusion • Increased intraocular pressure
• True ophthalmic emergency
• Sudden painless visual loss [Acute Angle Closure Glaucoma] Treatment
• “cherry red spot”, generalized retinal edema, opacification • Goal of treatment
• Precipitating factors: o Constrict pupil/ decongest the peripheral angle
o Arteriosclerosis o Increase IOP o Improve outflow/ decrease aqueous production
o Hypertension o Embolization o Dehydrate the vitreous
o Diabetes • Agents

o Anticholinergic – Pilocarpine
• Treatment: within 45 – 90 minutes (golden period)
o Beta blockers – Timolol, Betaxolol
o Carbogen, brown paper bag breathing
o Carbonic Anhydrase Inhibitor – Acetazolamide (Diamox)
o Efforts to decrease IOP and dislodge the embolus/clot
o Osmotic agents – Glycerol, Mannitol
§ Digital massage

§ IV Acetazolamide
[Acute Angle Closure Glaucoma] Surgical Management
§ Anterior Chamber Paracentesis
o Pharmaceutical: Systemic antithrombotic agents • Iridotomy
o Surgical o involves the use of surgical instruments—or more often, a
OCULAR EMERGENCIES
§ Core Vitrectomy with direct Central Retinal Art. massage laser—to punch a tiny, half-millimeter hole in the iris through
§ Panretinal Photocoagulation for Neovascularization which the trapped fluid can drain.
Jesus F. Marin, M.D.
§ Anti-VEGF treatment – prevent formation of new BVs • Iridectomy

Department of Ophthalmology APRIL 25, 2017
o similar procedure to iridotomy, and it is usually performed for
2. Chemical Burns similar reasons. The difference is that rather than creating a hole
A true ocular emergency
• CHEMICAL BURNS in the iris, the surgeon removes part of it.

• Alkali more serious than acid
• A true ocular emergency
o Caustic Soda (NaOH), Liquid Sosa (lye)
• Alkali more serious than acid
• Immediate irrigation – essential
• Immediate irrigation – essential

left: Iridotomy | right: iridectomy


IRRIGATION OF CHEMICAL BURNS SHOULD BE INITIATED ' it is mistakenly labeled in the PPT, but doc explained it.
IRRIGATION OF CHEMICAL BURNS SHOULD BE INITIATED BEFORE
BEFORE ARRIVAL AT EMERGENCY CENTER See also the description for your guide to avoid confusion.

ARRIVAL AT EMERGENCY CENTER
[Chemical Burns] Initial Emergency Measure
Before arrival at ER – immediate tap water irrigation initiated
• INITIAL EC MEASURE
• At the ER – topical anesthesia and lid retractor → copious irrigation
• Topical anesthesia
with several liters of normal saline solution
• Copious Irrigation
• Determine the nature of chemical burn
• Check for foreign bodies
[Chemical Burns] Treatment after thorough irrigation
• EC TREATMENT FOLLOWING IRRIGATION
Topical cycloplegia
• • Topical cycloplegic
Topical antibiotic
• Patch eye
• Topical antibiotic

• Prompt referral to ophthalmologist
• Patch eye
• Topical steroids
• Prompt referral to ophthalmologist

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2. Endophthalmitis 2. Optic Neuritis
• ' inflammatory condition of the intraocular cavities (ex. the • Inflammation of the optic nerve
aqueous and/or vitreous humor), usually caused by infection. o Invariably leads to Multiple Sclerosis
• possible complication of all intraocular surgeries, particularly o 15 – 20% of MS present with Optic Neuritis
cataract surgery o 35 – 40% of MS will progress to Optic Neuritis

[Endophthalmitis] Etiology [Optic Neuritis] Clinical Symptoms
• Intraocular surgery • 70% unilateral | 30% bilateral
• Trauma • Triad of:
• Leaking glaucoma filtering bleb o Loss of vision
• Endogenous source (infection of the lungs, urinary tract, etc.) o Ipsilateral eye pain
o Dyschromatopsia – color perception disturbance
[Endophthalmitis] Management • Fundus Signs:

• Vitreous culture
• Vitrectomy
• Antibiotic – intravitreal, systemic, topical

V. ACUTE ORBITAL DISEASE

1. Orbital Cellulitis

• " usually a disease of childhood and due to spread of infection Normal (65%) Edematous (35%) Atrophic (recurrent)
from the ethmoid sinuses
• Characterized by: [Optic Neuritis] Treatment
o Proptosis, pain, eyelid swelling, fever
• Oral prednisone
o " + erythema, limitation of EO movements, systemic upset with
o Did not have a better outcome than those given placebo
leukocytosis o Increased rate of recurrent optic neuritis

• Causes of Orbital Cellulitis o No benefit for typical cases of optic neuritis and may even
o Trauma predispose patients to further attack

o Immune-compromised patients • High dose IV Methylprednisolone + oral prednisone
o Infection of paranasal sinuses o IV methylprednisolone (250 mg qid x 3 days) followed by oral

• Different from Preseptal Cellulitis prednisone (1mg/kg/day x 11 days)

o " ⏯ No proptosis or limitation of eye movement o faster recovery of visual function
o May be due to localized infection in the anterior (pre-septal) o Final Visual Acuity after 6 months did not differ from that of
portion of the eyelid or; placebo-treated patients
o may be the early manifestation of orbital cellulitis o Associated with a reduced rate of development of multiple
sclerosis over a 2-yr follow-up period

VI. ACUTE WHITE EYE

[Optic Neuritis] Prognosis
1. Rhegmatogenous Retinal Detachment • Visual Recovery: Irreversible optic nerve damage occurs in 80% of
• " Most common type of retinal detachment patients, but recovery of Snellen acuity is good
• Caused by ≥1 full thickness breaks in the sensory retina, variable o 65-80%: 20/30 or better
degrees of vitreous traction, and passage of liquefied vitreous o 45% recover within the first 4 months
through the breaks into the subretinal space o 35% recover near normal acuity at 1 year
• ⏯ initial complaint: seeing floaters o 20% fail to make any significant improvement

[RRD] Pathophysiology 3. Retinoblastoma

• Most common intraocular malignancy of childhood
Vitreoretinal traction at points of adhesion o Metastatic – most common in general (both children & adults)
⬇ § Male – from lungs; Female – from breast
Transmission of energy to the retina • 1 in 20,000 live births; rarely seen after 7 y/o
⬇ • Prognosis is directly related to the size and degree of extension
Break/ hole formation relieves traction, but allows
o Intraocular = possible cure
liquid vitreous access to SR space
o With orbital extension = poor prognosis
⬇
• LIFE THREATENING; IMMEDIATE OPHTHALMOLOGIC REFERRAL
Neurosensory retina separates from RPE
⬇ [Retinoblastoma] Signs and symptoms
Retina becomes edematous and opaque
⬇ o Leukocoria o Proptosis
Photoreceptor degeneration and atrophy in time o Squint o Inflammation
o Photophobia o Glaucoma
{'} see complete discussion in Retina Trans
[Retinoblastoma] Prognosis

• Bilateral – within 15 months; average = 8 mos.

• Unilateral – by 20-30 months; average = 25 mos.

• 90% within 3 years

• Rare after 7 years

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4. Retinopathy of Prematurity (ROP)

• Stage 3
[ROP] Pathophysiology o Fibrovascular proliferation on the edge of the ridge
• Sufficient Cause: Immature Retinal Vasculature o Mild, moderate or severe vitreous infiltration
o Prematurity o 50% chance of progression to stages 4 and 5 and blindness
o Low Birth Weight o Threshold
• Potentiated by excessive oxygen administration § Zone 1 or 2 in 5 or more continuous clock hours
• Influenced by maternal and neonatal factors § Zone 1 or 2 with 8 cumulative hours of involvement with the
presence of “plus disease”
[ROP] Maternal Factors § Intervention within 72 hours of diagnosis
o Pre-Threshold
• Alcohol • Glucocorticoids
§ Zone I any stage
• Anemia • Multiple Births
§ Zone II stage 2+ or stage 3
• Diabetes • Threatened Abortion
§ LIO (Laser Indirect Ophthalmoscope) within 48 hours of dx
• Drugs (antihistamines) • Tobacco

• PPROM • Toxemia of Pregnancy • Stage 4:

o Fibroproliferative scar contraction & Partial Retinal Detachment
[ROP] Neonatal Factors § 4A - detached outside of the macula/ fovea (zone 1)
• Acidosis • Hypotension § 4B - retinal detachment involving the macula/ fovea
• Alkalosis • Hyperoxia o Poor Visual Prognosis

• APGAR score • Hypoxia • Stage 5:

• Apnea • Intracranial Hemorrhage o Total Retinal Detachment with a closed or partially closed
• Birthweight • IUGR funnel, from the Optic nerve to the retrolenticular space
• Bradycardia • Indomethacin o Essentially no useful vision
• Bronchopulmonary Dysplasia • Light o Treatment: Surgical
• Endotracheal Intubation • Patent Ductus Arteriosus

• Plus Disease
• Exchange Transfusion • Respiratory Distress Syndrome o With abnormal iris vessels/tortuosity and engorgement of
• Gestational Age • Sepsis retinal vessels
• Vitamin E Deficiency • Ventilatory Support o Rush Disease – plus disease involving zone 1 – very rapid
progression
[ROP] Examination Sequence
th th
• Screen at about the 4 – 8 week of age
• Repeat every 1 – 2 weeks until the ff:
o Normal and complete blood supply develop
o Successive 2-week exam shows Stage 2 in zone III;
then, every 2 – 4 weeks
o Development of “prethreshold” – weekly
o ROP disappears
• Once blood supply completed — every 6 – 12 months
Stage 4A – macula is spared/ Stage 4B – macula is not spared/

still attached already detached
[ROP] ICROP Classification

Zone 1 Area around the optic nerve about 2x papillofoveal radius

Zone 2 From edge of zone 1 to the anterior nasal edge of the
retina
Zone 3 Remaining temporal crescent of retina from the edge of
zone 2

Stage 5 – total retinal detachment with a closed funnel

[ROP] Treatment
• Objective: Ablate Ischemic Retina
• Modalities:
o Cryotherapy, Laser Photocoagulation, Indirect Ophthalmoscope
Surgical / Endolaser, Endoptik, Laser Diopexy
o Laser Retinopexy

• Stage 1 Advantages Disadvantages

o Characterized by a demarcation line separating normal § Less need for anesthesia § Limited trial
vascularized retina from undeveloped retina § Less pain & swelling § Technical diff. of focus and
o Line is typically white § Less ocular damage & ablation
o Marked contrast between regions cardio-respi effect § Needs completely flat

§ Less myopia retina and lesions
• Stage 2

o Rolled pink ridge in place of the demarcation line that has

increased in width & height

o Limited to a small sector or may encircle the entire posterior

pole

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VII. OCULAR TRAUMA 3. Injuries to the Globe: Conjunctiva

a. Conjunctival Foreign Body

Protective Mechanism
• Orbital rim • Remove by irrigation, spud, or cotton tipped applicator
• Lashes and lids • Foreign body frequently lodged at upper tarsal conjunctiva
• Blink/Bell’s reflex • ⏯ Always evert upper eyelid in examining the eyes so as not to miss
• Tears and lacrimal system lodged foreign bodies

Examination
• A drop of topical anesthesia may facilitate evaluation
• Exposure/tension may be dangerous when there is perforation
• Retract and fix lids only over the orbital rim and not the globe

⏯ Always get the visual acuity first before applying or doing any
maneuver in order to obtain a baseline if ever the patient tells you that
there is a decrease in visual acuity upon application of anesthesia.
This is to protect yourself from medicolegal cases.

b. Subconjunctival Hemorrhage
Types of Trauma
• May be secondary to:
• Blunt
o Blunt trauma
• Penetrating/ Perforating
o Valsalva maneuver (coughing, etc.)
• Chemical/ Thermal Burns
o Hypertension

o Bleeding disorder
Birmingham Eye Trauma Terminology System (BETTS)
o Idiopathic
• ⏯ Presentation: vision is normal, patient only panics once he sees it
on the mirror.
• Management: cold compress, reassurance, lubricants

c. Conjunctival Laceration
• Lacerations of bulbar conjunctiva that do not involve the globe and
rarely require surgical closure
• Usually surrounded by subconjunctival hemorrhage


• Laceration is evident as a white, crescentic area
1. Blunt Trauma

• Sphincter pupillae muscle may be ruptured, resulting in semi-dilated
4. Injuries to the Globe: Sclera
pupil that does not react to light (iridoplegia)
• Limbus or just posterior to muscle insertion
• Iris may be torn from its insertion to the scleral spur causing
• Look out for asymmetric decrease in IOP, anterior chamber depth,
iridodialysis
irregularity of pupil and hyphema
• Tear a portion of the lens zonule, causing the lens to become

subluxated
Corneoscleral Laceration
• For repair – expose lacerated area by dissecting the cut edges of the
conjunctiva and tenon capsule from the scleral laceration
• Prolapsed uveal tissue excised and vitreous removed
• Sclera closed with interrupted sutures
• Conjunctiva closed separately

5. Injuries to the Globe: Cornea
Inferior iridodialysis Traumatic aniridia Rupture of the globe

a. Corneal Abrasion
2. Contusion Hematoma/ Traumatic Iritis/ Black Eye • Fluorescein dye – used in detection
• Secondary to blunt ocular injury o Without the aid of dye, the opaque area is where the abrasion is
• Presentation: • Small abrasions – topical antibiotics
o BOV, Photophobia, Lacrimation, Sphincter rupture, Iridoplegia • Bigger abrasions – eye patch/ bandage/ contact lens
o Review: Difference between Lacrimation and Epiphora? • Symptoms: FB sensation, Tearing, Photophobia, Pain
§ Lacrimation – overproduction • Treatment: Topical cycloplegic, Topical antibiotic, Pressure Patch

§ Epiphora – affected drainage
§ Both causes overflowing of tears/ tearing
• Hemorrhagic chemosis sever hypotony may imply a rupture
• Conjunctival injury – heals quickly and may mask perforations

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b. Corneal Foreign Body • Diagnosis and Treatment depend on the following factors:
• Depend on material and depth of cornea o Size of the foreign body – Roentgen-ray, Ultrasound, CT-scan
• Superficial FB – removed by G 25 needle or spatula o Magnetic Prop. – only Nickel & Iron may be removed by magnet
• Metallic FB – you also have to remove the rust ring formed o Tissue reaction – Siderosis
o Location within the eye

9. Eyelid Thermal Burns

First-degree Erythema and mild edema of the eyelid

No loss of epidermis
Second-degree Epidermal loss
More painful
rust ring
Blisters and oozing of serous fluid
c. Corneal Lacerations Lid contraction
Third-degree Full thickness skin
• Penetrating injury
Charring and white-brown waxy consistency
• May be accompanied by injury to iris, lens, and retina
Usually are not painful


6. Injuries to the Globe: Iris
10. Lid Lacerations
• Traumatic miosis

• Traumatic mydriasis Superficial Lid Laceration

• Iridodialysis • Avoid lid margin retraction
• Hyphema* • Give tetanus prophylaxis
• Remove superficial foreign bodies
Traumatic Hyphema • Rule out deeper foreign bodies

Grade 1 Layered blood occupying < 1/3 of the anterior chamber • Wound of the eyelid must be carefully cleaned with soap and water
Grade 2 Blood filling 1/3 – 1/2 of the anterior chamber • Lacerations parallel to eyelid margins are closed with fine sutures
Grade 3 Layered blood filling ½ to < total of the anterior chamber • Vertical lacerations are divided into:
Grade 4 Total clotted blood, often referred to as black ball/ 8-ball o Outer 5/6 of the eyelid (ciliary) margin
o Inner 1/6 of the eyelid (lacrimal) margin which avulse the
• Hyphema Management canaliculi leading to the tear sac

o Light activity or even bedrest – to prevent a rebleed into the • Ciliary margin
anterior chamber, which may cause obstruction of vision, or a o Outer 5/6 of eyelid margin
painful rise in pressure o Place first suture thru gray line of eyelid to align eyelid margin
o Elevation of the head of the bed by approximately 45 degrees – o Remainder of the eyelid can be closed in layers with catgut
so that the hyphema can settle out inferiorly and avoid sutures for the tarsus and silk for the skin
obstruction of vision, as well as to facilitate resolution

o Wearing of an eye shield at night time – to prevent accidental • Lacrimal margin

rubbing of the eyes during sleep → can precipitate a rebleed o Inner one sixth of the eyelid that sever a canaliculus
o Avoidance of pain medications (aspirin/ibuprofen) – which thin o Placement of a stent thru the canaliculus to remain patent
the blood and increase the risk of a rebleed - instead, o Closure of laceration
acetaminophen can be used for pain control o Prevention of traction by the orbicularis oculi muscle located
lateral to the laceration
7. Injuries to the Globe: Lens
• Cataract 11. Isolated Blow-Out/ Orbital Floor Fractures
• Subluxated Lens • Direct blunt injury
• Intact orbital rim
8. Injuries to the Globe: Posterior Pole • Presentation: Diplopia, Hypotropia
• Commotio retinae • Diagnostic modalities:
• Traumatic macular edema/ Berlin’s edema o EOM evaluation
• Optic nerve head avulsion – loss of vision o Forced duction test
• Intraocular foreign bodies* o Imaging techniques
• Management:
Intraocular Foreign Body o Surgery indicated only for persistent diplopia or poor cosmesis
• Present in injuries in w/c small particles penetrate the cornea/ sclera o Surgery can be delayed since diplopia may be transient
• Large foreign bodies markedly disrupt the globe and cause so much
associated injury that the eye may be disorganized and require
eventual enucleation
• A sharp, pointed metallic intraocular foreign body (IOFB) rests on
the retina, covered by a small amount of vitreous hemorrhage
• Commotio retinae

• A- and B-scan ultrasound

o show the shadowing behind the IOFB and the anechoic zone
Reference: PPT by FEU-NRMF Department of Ophthalmology
extending into the sclera
Credits to K. Guzman, K. Cai for the pictures of the slides. (
o low-lying retinal detachment caused by a hole from the IOFB
No proofreading done. Feel free to correct during discussion.

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