OPHTHALMOLOGY

EMERGENCIES
ANATOMY OF THE EYE
INFECTIONS & TRAUMA ACUTE VISION LOSS
INFLAMMATION • Corneal Abrasion • Acute Angle Closure
• Scleritis • Corneal Foreign Bodies Glaucoma
• Episcleritis • Blunt Eye Trauma • Optic Neuritis
• Keratitis • Orbital Blowout • CRAO
• Conjunctivitis Fractures • CRVO
• Orbital Cellulitis • Chemical Injuries • Retinal Detachment
• Subconjunctival • Retinal Haemorrhage
Haemorrhage
• Vitreous Haemorrhage
• Temporal Arteritis
INFECTIONS & INFLAMMATION
 Scleritis
• Definition : Inflammation of the sclera
• History :
Severe, boring pain, worse with eye movement,
progresses insidiously over weeks. Blurring of vision,
teary, red eye, headache
• Examination : Dilatation of the deep episcelral vessels,
thinning of sclera resulting in a bluish discoloration
• Management : oral NSAID
Episcleritis
• Episcleritis is benign recurrent inflammation
of the episclera, involving the overlying
Tenon’s capsule but not the underlying sclera
• Symptoms- redness, mild ocular discomfort
(described as gritty, burning or foreign body
sensation)
• Signs- simple episcleritis: sectorial
inflammation of episcleritis
- modular episcleritis: pink or purple flat
nodules surrounded by injection, usually 2-3
mm away from limbus
Episcleritis
• Management-artificial tears
• - 0.1% dexamethasone eye drops 1 drp
TDS x 1/52
-may allow discharge with ophthalmology
follow up
Keratitis
• Definition : Inflammation of cornea
• Causative : Bacterial, Viral (Herpes simplex virus (HSV) varicella-
zoster virus (VZV) , and cytomegalovirus (CMV) ( CMV & VZV are
less common) , Fungal
• History : Photophobia, foreign body sensation, tearing, and
exquisite pain
• Examination : Perilimbal injection
Slit lamp exam : Cells and flare at anterior chamber
Management : Referral stat
Conjunctivitis
• Definition : Inflammation of conjuctiva
Causative
• A) Bacterial : Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus
influenzae and Moraxella catarrhalis.
• B) Viral : Adenovirus
• C ) Acute Allergic conjuctivitis: an environmental allergen, usually pollen. It is
typically seen in younger children after playing outside in spring or summer.
Conjunctivitis
• Management :
• Bacterial : Topical antibiotics, usually four times daily for up to a week .
• Chloramphenicol, aminoglycosides (gentamicin, neomycin, tobramycin), quinolones
(ciprofloxacin, ofloxacin, levofloxacin, lomefloxacin, gatifloxacin, moxifloxacin,
besifloxacin), macrolides (erythromycin, azithromycin) polymyxin B, fusidic acid and
bacitracin.
• Viral : Spontaneous resolution of adenoviral infection usually occurs within 2–3 weeks
• Reduction of transmission risk by meticulous hand hygiene,
• avoiding eye rubbing and towel sharing.
Orbital Cellulitis
• Orbital cellulitis refers to an acute
infection of the soft tissues of the orbit
• Symptoms- swelling and severe pain
- may be associated with fever,
nausea, vomiting, prostrations and
sometimes loss of vision
• Signs- swelling of lids characterised by
woody hardness and redness, chemosis of
conjuctiva, axial proptosis, restrictions of
ocular movements
Orbital Cellulitis
• Management
- IV analgesics
- IV antibiotics started by
ophtalmologist
- immediate ophthalmology
referral
TRAUMA
Corneal Abrasion
Traumatic abrasions may cause superficial or deep epithelial defects
resulting in tearing, photophobia, blepharospasm, and pain.
• A corneal abrasion will glow green during a fluorescein stain
examination when using the cobalt blue light on the slit lamp.
• A careful search for an ocular foreign body (including upper lid
eversion) must be done in the presence of an abrasion, especially
when they are multiple and linear .
Management :
• prescribe ketorolac ophthalmic solution one drop four times a day for pain control.
• For severe pain with large abrasions, opioid analgesia and/or a cycloplegic (e.g.,
cyclopentolate 1% one drop three times a day)
• Abrasions are treated with topical antibiotics.
Most patients are treated with erythromycin ointment; however, abrasions
associated with contact lens wear should be treated with antipseudomonal topical
antibiotics (e.g., ciprofloxacin, ofloxacin, )
Corneal Foreign Bodies

• Common types.
1) In industrial workers are particles of iron (especially in lathe and hammer-chisel
workers),
and coal.
2) In agriculture workers, these are husk of paddy and wings of insects.
Other common foreign bodies are particles of dust, sand, steel, glass, wood and small
insects (mosquitoes).
• Symptoms.
Discomfort, profuse watering and redness in the eye.
Pain and photophobia are more marked in corneal foreign body than the conjunctival.
Defective vision occurs when it is lodged in the centre of cornea
Corneal Foreign Bodies
• foreign bodies of the cornea are removed under slit lamp microscopy with a 25-
guage needle, an eye spud, or an ophthalmic burr.
• Stat opthal referral
• After removal of foreign body, pad and bandage with antibiotic eye ointment is
applied for 24 to 48 hours. Antibiotic eye drops are instilled 3-4 times a day for
about a week.
• Prevention. Industrial and agricultural workers should be advised to use special
protective glasses. Cyclists and scooterists should be advised to use protective plain
glasses or tinted goggles.
Blunt Eye Trauma
• Modes of injury
Blunt trauma may occur following:
• Direct blow to the eye ball by fist, ball or blunt instruments like sticks, and big stones.
• Accidental blunt trauma to eyeball may also occur in roadside accidents, automobile accidents, injuries
by agricultural and industrial instruments/ machines and fall upon the projecting blunt objects.
• Modes of damage
The different forces of the blunt trauma may cause damage to the structures of the globe by
one or more of the following modes:
1. Mechanical tearing of the tissues of eyeball.
2. Damage to the tissue cells sufficient to cause disruption of their physiological activity.
3. Vascular damage leading to ischaemia, oedema and haemorrhages.
4. Trophic changes due to disturbances of the nerve supply.
5. Delayed complications of blunt trauma such as secondary glaucoma, haemophthalmitis, late rosette
cataract and retinal detachment.
Blunt Eye Trauma
• An eye speculum (or two bent paper clips) may be useful in visualization of the
bluntly injured eye, but care should be taken to avoid any pressure on the globe.
• Once the eye is visualized, the integrity of the globe and visual acuity must be
assessed immediately.
• Red flag signs abnormal anterior chamber depth, an irregular pupil, or blindness
indicate a ruptured globe until proven otherwise, and an emergent ophthalmology
referralis indicated.
• An eye shield should be placed as soon as a globe injury is suspected to protect
against further injury.
Orbital Blowout Fractures
• The term blowout, or hydraulic fracture, describes an
orbital floor fracture caused by sudden increase in
intraorbital pressure which is not accompanied by an
orbital rim fracture.
• This may be produced by a blunt or round object
striking the front of the orbit with considerable force,
thus suddenly displacing the orbital contents
posteriorly and disseminating this increased pressure
in all directions.
• The resultant entrapment of the inferior rectus muscle
may cause restriction of movement, with a resultant
diplopia on upward gaze.
• Other signs include paresthesia in the distribution of
the infraorbital nerve and subcutaneous emphysema,Source : Blowout Fracture of the Orbit , In the
particularly when sneezing or blowing the nose. absence of diplopia and exophthalmos , REESE W.
PATTERSON, JR., M.D. , RAY V. DEPUE, JR., M.D. ,
1963
Orbital Blowout Fractures
• If a blowout fracture is suspected, CT of the orbit is
indicated.
• Refer all isolated blowout fractures, with or without
entrapment, to an ophthalmologist for a formal
dilated exam to rule out retinal injury.
 Hyphaema
• Definition : a collection of blood in the anterior chamber.
• vary from diffuse red blood cells circulating in the aqueous humor to
a hemorrhage that fills the entire anterior chamber
• Most often is caused by trauma or intraocular surgery, but may also
occur spontaneously in patients with :
rubeosis iridis , vascular tufts at the pupillary margin, juvenile
xanthogranuloma, iris melanoma, myotonic dystrophy, keratouveitis,
leukemia, hemophilia, Thrombocytopenia and Von Willebrand disease.
• Hyphema may also be associated with drugs that alter platelet or
thrombin function, such as aspirin or warfarin
Source : Traumatic Hyphema: A Teaching Case Report , Priscilla Lenihan, OD Dorothy Hitchmoth, OD, FAAO , 2014
Hyphaema
• Grading :
Treatment :
• Aimed at preventing secondary hemorrhage, preventing further trauma to the eye,
promoting the settling of blood to the bottom of the anterior chamber and
controlling traumatic uveitis.
• Hospitalization should be considered for patients with severe injuries or blood
disorders and those who are not capable of self-care or may be noncompliant with
the treatment regimen.
• eye protection with plastic or metal shields
• limited physical activity
• elevation of head posture (Having patients sleep at a 30- 45-degree angle promotes
more rapid blood resorption and lowers venous pressure to the globe, helping to
reduce IOP and to allow for clot formation and resolution )
• avoidance of aspirin and other non-steroidal anti-inflammatory agents
• Most hyphaemas absorb spontaneously.
• Sometimes hyphaemas may be large and associated with rise in IOP.
• IOP need to be lowered by acetazolamide and hyperosmotic agents.
• If blood does not get absorbed in a week’s time, and IOP is raised, then paracentesis
should be done to drain blood.
Chemical Injuries
• Examples: Acid- hydrochloric acid (used to clean swimming pool), sulfuric acid (in car
batteries); Alkali- sodium hydroxide (household cleaning products, industrial cleaning
products), ammonia (fertilizers), calcium hydroxide (cement, plaster)
• Symptoms- pain, tearing, red eyes, sudden loss of vision
• Signs- ulceration of cornea, photophobia, purulent discharge
• Management-
 Immediately flush with sterile normal saline, until ph remains at or near 7.4
 After first 2L of irrigation, ph checked in lower cul-de-sac with litmus paper
 Irrigation should be continued until normal ph can be maintained at least 30 minutes after
cesation (volume may go up to 8-10L)
 Once ph is normal, the fornicles should be inspected and eyelids should be everted to look for
any residual particles
 The ph should be checked every 10 minutes for 30 minutes to make sure that no additional
corrosive is leeching out from the tissue
 A slit lamp examination should be done, IOP should be measured
• Immediate ophthalmology referral if signs of severe injury- chemosis, conjunctival
blanching, epithelial defect, corneal oedema
• Discharge with cycloplegic- cyclogyl 1% eye drop 1 drop TDS, erythromycin 0.5%
ophthalmic ointment 1-2 hours while awake
Subconjunctival Haemorrhage
• Subconjunctival haemorrhage occurs due to rupture of blood vessels in conjunctiva
causing blood to leak between conjunctiva and sclera

• Symptoms/ signs- red spots over conjunctiva

• Management- usually harmless and self heals in 2 weeks- reassurance
- may allow discharge with ophthalmology follow up
ACUTE VISION LOSS
Acute Angle-Closure Glaucoma
• Definition : occurs when Intraocular pressure rises rapidly as result of sudden
blockage of the trabecular meshwork
• History : Unilateral frontal headache with ocular pain, nausea and vomiting, decreased
vision, haloes around light.

• can be precipitated in movie theaters, while reading, and after ill-advised use of dilatory
agents or inhaled anticholinergics or cocaine.

• Physical examination : Diffusely reddened congested eye

Decreased visual acuity
hazy cornea
pupil mid- dilated (4-6mm) , non reactive
Positive oblique flash light test
Shallow anterior chamber
increased IOP of 40 to 70 mm Hg (normal range, 10 to 20 mm Hg)
Management :
• immediate ophthalmologic consultation
• Place the patient supine
• Decrease aqueous production with IV acetazolamide 500mg stat
• Timolol eyedrop ( one drop stat and 2nd drop in 10 mins)
• Increase aqueous flow with 4% pilocarpine eyedrop , one drop every 15 mins for 1 hour,
then 4 drops hourly.
• IOP should be monitored hourly
 Optic Neuritis
• Optic neuritis is inflammatory and demyelination disorders of the
optic nerve

• Symptoms- sudden, progressive, profound unilateral visual loss

- pain for a few days, increased by eye movements

• Signs- reduced and painful visual acuity, Marcus Gunn pupil which
indicates relative afferent pupillary defect

• Management- IV steroids followed by oral steroids

- IV hydrocortisone 2-4mg/kg (max 100mg) 6 hourly, T.
Prednisolone 1-2 mg/kg (max 60mg) OD
- immediate ophthalmology referral
Central retinal artery occlusion (CRAO)
• CRAO is a medical and ophthalmic emergency and need to be
promptly evaluated for stroke
• Common cause of CRAO is carotid artherosclerosis

• Symptoms- painless unilateral loss of vision, may present with

transient visual loss (amaurosis fugax) in the past

• Signs- reduced visual acuity, absence of direct pupillary reflex

(afferent pupillary defect), pale oedematous retinal, markedly
reduced vascularise, cherry red spots

• Evaluation- carotid artery Doppler, CT angiography

• Management- therapy should be started within 6 hours of onset of symptoms to
prevent irreversible vision loss
Treatment Mechanism of Action

IV acetazolamide 500mg Reduce intraocular pressure

IV mannitol 0.25-0.5g/kg Reduce intraocular pressure

Topical anti-glaucoma medications Reduce intraocular pressure

Sublingual isosorbide dinitrate Vasodilation to increase blood oxygen content

IV hydrocortisone 2-4mg/kg (max 100mg) 6 hourly Reduce retinal oedema

IV or intra-arterial recombinant tissue plasminogen
Thrombolytic therapy to dissolve clot
activator (rt-PA)
Hyperbaric oxygen therapy Increase blood oxygen tension

Ocular massage Reduce intraocular pressure

• Immediate ophthalmology referral
Central Retinal Vein Occlusion (CRVO)
• Symptoms- painless unilateral loss of vision

• Signs- reduced visual acuity

- engorged tortuous retinal veins without
physiologic pulsation

• Management- treat underlying cause –

hypertension, diabetes mellitus
-T. aspirin 300mg, T.plavix 300mg,
IV hydrocortisone 2-4mg/kg (max 100mg)
Retinal Detachment
• Retinal detachment is the separation of neuro-sensory retina proper from the
pigment epithelium

• Symptoms- painless unilateral loss of vision preceded by streaks or flashes of light

• Signs- fundoscopy shows grey, billowed or folded area of retina, with an overlying
vessels having an undulating course

• Management- immediate ophthalmology referral

Retinal Haemorrhage
• Symptoms- painless unilateral loss of vision

• Signs- focal or generalised reduction in visual acuity

- fundoscopy shows retinal haemorrhage

• Management- immediate ophthalmology referral

Vitreous Haemorrhage
• Vitreous haemorrhage usually occurs from the retinal vessels and may present as
pre-retinal or intra-gel haemorrhage.

• Symptoms- small: sudden development of floaters

- massive: sudden painless unilateral loss of vision

• Signs- reduced visual acuity

- vitreous floaters on fundoscopy

• Management- bed rest and place patient in upright position

- immediate ophthalmology referral
Temporal Arteritis (Giant Cell Arteritis)
• Temporal arteritis is a systemic vasculitis causing painless ischemic optic neuropathy
• Sight threatening emergency as visual loss is usually permanent
• Symptoms- sudden painless visual loss, unilateral temporal headache, jaw claudication,
scalp or temporal artery tenderness, fatigue, fever, sore throat, URTI symptoms,
anorexia
• Signs- Temporal artery tenderness with decreased pulsation,
Afferent Pupillary Defect (APD), flame haemorrhages, 6th cranial nerve palsy
• Investigations- ESR and CRP usually elevated
• Management- T. Prednisolone 30-60mg stat if diagnosis is confirmed
- IM voren 50mg stat as analgesics
- immediate ophthalmology referral
References
• Shirley Ooi, Guide to the Essentials in Emergency Medicine, 2nd Edition
• Tintinalli’s Emergency Medicine Manual, 8th Edition
• AK Khurana Comprehensive Ophthalmology, 5th Edition
• REESE W. PATTERSON, JR., M.D. , RAY V. DEPUE, JR., M.D Blowout Fracture of the
Orbit , In the absence of diplopia and exophthalmos , 1963
• PRISCILLA LENIHAN, OD DOROTHY HITCHMOTH, OD, FAAO Traumatic Hyphema: A
Teaching Case Report , 2014
THANK YOU