Ocular Emergencies

Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital

Ocular Anatomy

Bony Components of Orbit

1

1. Frontal

bone

2. Zygomatic bone
3. Maxillary bone
4
7 6

5

4. Sphenoid 5. Ethmoid
3

bone bone

6. Lacrimal bone 7. Palatine bone

2

Size 30 x 40 x 45 mm

Paranasal Sinus

Ocular Anatomy Orbicularis Oculi .

Ocular Anatomy .

Ocular Anatomy .

Ocular Anatomy .

Extraocular Muscles .

Optic Nerve .

Venous System .

trauma .Ocular Emergencies Blunt trauma Trauma Penetrating trauma Non .

Acute Eye Conditions Emergency ( Immediately ) Very Urgent ( Within a few hours ) Urgent ( Within one day ) Retinal arterial occlusion Chemical burns Perforation Ruptured Acute glaucoma Orbital cellulitis Orbital injury Corneal ulcer Sudden congestion proptosis Corneal abrasion 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 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 Central Retinal Artery Occlusion Orbital Cellulitis Cavernous Sinus Thrombosis Endophthalmitis Retinal Detachment Toxic Causes of blindness .

Corneal Abrasions 7. Lacerations of the Eyelids 3. Ecchymosis of the Eyelids 2. Corneal & Conjunctival Foreign Bodies .& Orbit 1.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. Fracture of the Ethmoid bone 5. Blowout Fractures of the Floor of the Orbit 6. Adnexa. Orbital hemorrhage 4.

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

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

2.1% tropicamide ( Mydriacyl ) .Fundus Examination A dilated pupil makes it easier to see the optic nerve. macula.5% phenylephrine ( Neo-Synephrine ) PanOptic Ophthalmoscope Indirect Ophthalmoscope . and retina .

Intraocular Pressure Measurement Digital palpation Schiotz tonometer .

Ocular Trauma Closed Globe Burn Contusion Laceration Open Globe Rupture Laceration Penetrating Perforating .

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

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

Corneal Abrasion : Management Searching for conjunctival foreign body Topical cycloplegia. ATB ointment Pressure patching for 24 hours Don’t 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 0 I II III IV Size of Hyphema No layered blood circulating red blood cells only Less than 1/3 1/3 to 1/2 1/2 to less than total Total .

Traumatic Hyphema .

measure IOP Reduce IOP Ophthalmology consult .Traumatic Hyphema : Management Elevate the patient’s 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.

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 .Mucocutaneous junction .Lash line .Gray line .

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 can’t be R/O Refer immediately to ophthalmologist .

Intraocular or Intraorbital Foreign Bodies .

Ocular Trauma Traumatic cataract Traumatic lens subluxation Traumatic mydriasis Traumatic lens subluxation .

Acid burns tend to coagulate proteins. causing damage to intraocular structures. .Chemical Ocular Injury True ocular emergency Both acid and alkali burns can be blinding . .Alkali burns can rapidly penetrate the cornea. limiting the depth of penetration.

Chemical Ocular Injury : Management Immediate copious irrigation with a minimum of 1-2 L of saline or until pH is normalized ( 7.7 ) .Instill a topical anesthetic .Use eyelid retractor .Double eversion of the eyelids .3-7.

Irrigation in case of chemical injury .

ATB + steroid eye drop Ophthalmologists Referral .Chemical Ocular Injury : Management Immediate copious irrigation with a minimum of 1-2 L of saline or until pH is normalized ( 7.Double eversion of the eyelids No corneal involvement .Use eyelid retractor .3-7.Instill a topical anesthetic .7 ) .

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 .

blurred vision with halos. and extreme pain in the left eye while in a movie theater. vomiting. Her vision has worsened since that time and the eye has become very red. nausea. .A 55-year-old woman with a red eye. and vomiting The woman suddenly experienced nausea.

A 55-year-old woman with a red eye. nausea. and vomiting VA .HM Conjunctival injection Hazy cornea Shallow anterior chamber Fixed mid-dilated pupil IOP 56 mmHg Acute Angle Closure Glaucoma . blurred vision with halos.

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 .

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 .Central Retinal Artery Occlusion Treatment must be initiated immediately.

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 .

20/25 RAPD +ve OD VF central scotoma OD Retrobulbar optic neuritis .A 36-year-old-woman with subacute visual loss in right eye and pain on eye movement VA 20/200.

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 .

headache. high level of C .A 73-year-old woman with acute visual loss of right eye. 20/25 RAPD + ve RE Arteritic anterior ischemic optic neuropathy ESR 94 mm/hr.reactive protein . anorexia and weight loss VA 10/200.

Pathology : Giant Cell ( Temporal ) Arteritis .

20/30 Dilated.A 35-year-old man with left painful third nerve palsy VA 20/25. 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. LP +ve RAPD LE What is the diagnosis? . visual loss and severe headache VA 20/30.

headache.Pituitary Apoplexy Characterized by sudden visual loss. 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 .

20/20 + ve RAPD RE Normal fundi LE RE .A 17-year-old man with right blured vision after minor blunt trauma. VA 20/32.

LP + ve RAPD LE Normal fundi .A 16-year-old man with head injury and left blured vision after falls from height VA 20/30.

Traumatic Optic Neuropathy : Classification and Mechanisms Direct injury .Injury from fractured bone . transection Indirect injury .Compression secondary to orbital hemorrhage or intrasheath hemorrhage . projectile .Contusion with transmission of force through bone .Avulsion.Penetrating injury from knife.

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 .

high.Medical Management Options Steroids : Controversial .Thought to limit free-radical amplification of the injury response Dosages ( low. 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 . .

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