Ocular Emergencies

OCULAR EMERGENCIES Medical Surgical Conjunctivitis Corneal Abrasion Iritis Periorbital Cellulitis Glaucoma Central Retinal Artery Occlusion Surgical Corneal Abrasion Extraocular Foreign Bodies Retinal Detachment Orbital Fracture Chemical Burns Hyphema Eyelid Laceration Globe Rupture

Assessment History / MOI Time of occurrence Treatment before arrival Abnormal eye appearance Visual acuity Snellen’s Visual Fields Finger count

Assessment Tearing Itching Discharge Medical History Ocular Systemic Medication Always use contralateral eye for comparison

Assessment Spasms of eyelid Lesions, FB, Penetrating wounds Pupils EOM Position and alignment of eye

Assessment Conjunctiva and sclera for color and inflammation Edema of lids, conjunctive, and/or cornea Blood Opaque, gray-white area of cornea Hazy cornea

Assessment Palpation Intraocular pressure: Do not do if there is concern regarding globe

Things To Think About When Assessing Younger males are at higher risk for serious injury School-age children are more susceptible to conjunctivitis Contact wearers are at greater risk for corneal abrasions and infection Exposure to arc welding S/S develop 4-8 post exposure

Things To Think About When Assessing Auto mechanics and service station attendants have potential for acid burns to face Injuries occurring in the garden have increased potential for infection Ball sports increase potential for eye injury

Diagnostics Direct ophthalmoscope Tonometry Fluorescein staining Slit-lamp exam Laboratory Cultures CBC Coags

Radiology Diagnostics CT scan Soft tissue/orbit films for foreign body Facial bones Skull films

Priorities ABCs Prevent further damage Prevent or minimize complications Control pain Relieve anxiety or apprehension Education

Consultation Criteria Penetrating ocular trauma Chemical burns of the eye Severe lid laceration Glaucoma Central retinal artery occlusion Retinal detachment Orbital fracture Hyphema Periorbital cellulitis

Age-related Pearls Pediatric Delayed presentation due to children not noticing gradual vision loss May need picture chart Infants and small children may need to be restrained in blanket to facilitate exam

Age-related Pearls Geriatric Vision diminishes gradually until 70 y/o and then rapidly thereafter Decreased near vision Decreased accuracy of results from visual acuity testing

Age-related Pearls Geriatric Decreased accommodation to distances Decreased lacrimal secretions Cataracts: at age 80 1 in 3 are affected More likely to experience glaucoma, detached retina, and retinal bleeds

Medical Ocular Emergencies

Conjunctivitis Inflammation of the conjunctiva Causes: bacterial/viral inflammation allergies Chlamydia chemical burns FB flash burns Irritants URI

Conjunctivitis Symptoms/Assessment Hyperemia Unilateral or bilateral Slight pain “Gritty” sensation Discharge Mucopurulent Matting of eyelids and lashes Edema of eyelids Visual acuity: Normal Cornea: Clear Pupil: Normal Conjunctiva: red or pink

Conjunctivitis Treatment Education Antibiotics ointment/drops Obtain culture, if indicated Cleanse eyes gently to remove debris Education Explain contagious nature Medication admin. Asepsis Wipe from nose to outer corner of eye Cleanse lid with baby shampoo Avoid eye makeup Follow-up

Iritis Inflammatory process that includes the iris and sometimes the ciliary body Predisposing conditions:rheumatic disease, and syphillis

Iritis Symptoms/Assessment Blurring of vision Unilateral pain Edema of upper lid Red eye Photophobia Decreased visual acuity Lacrimation Redness at eyelash Clear to hazy cornea Small, irregular, sluggish reaction of pupils Pain on eye pressure Fluorescein stain Slit-lamp exam

Iritis Treatment/Education Analgesics NSAIDs Rest eyes Cycloplegics to paralyze ciliary muscle and spasms Darkened environment Rest eyes Warm compresses Shield eyes or dark glasses Follow-up

Periorbital Cellulitis Infection of the cells around the eyes A major ophthalmological emergency and is potentially life threatening May occur after trauma such as laceration or an insect bite Pneumococcal, staphylococcal, streptococcal

Periorbital Cellulitis Symptoms/Assessment Marked periorbital edema and erythema Pain: severe that is aggravated by movement of eye Conjunctival infection Fever Visual acuity: Decreased Decreases pupil reflexes Paralysis of EOM Diagnostics CT scan Culture Gram stain Blood culture

Periorbital Cellulitis Treatment/Education Referral to ophthalmologist Bedrest IV therapy IV antibiotics Warm compresses

Glaucoma Acute angle-closure glaucoma occurs when the distance between the iris and the cornea becomes inadequate or is blocked completely The aqueous fluid produce is greater than the amount leaving through the canal of Schlemm Emergency Situation May lead to irrecoverable blindness

Glaucoma Symptoms/Assessment Tonometry Red eye Severe, sudden-onset, deep, unilateral pain Intense HA Decrease visual acuity Halos around lights N/V Abdominal pain Hazy, lusterless cornea Pupils poorly reactive or fixed Increased intraocular pressure (>20 mm Hg) Rocklike harness appearance Diagnostic Tonometry

Glaucoma Treatment/Education Referral to ophthalmologist Analgesic Antiemetic Pilocarpine eyedrops Osmotic diuretic Supportive and informative environment

Central retinal occlusion Blockage of the the retinal artery by thrombus or embolus True ocular emergency Prompt recognition and intervention must be obtained within 1-2 hours of onset

Central retinal occlusion Symptoms/Assessment Sudden unilateral loss of vision Painless History of: Thrombus or embolus HTN Diabetes Sickle cell disease Trauma Visual acuity is limited to light perception in affected eye Pupil reaction: dilated, nonreactive in affected eye

Central retinal occlusion Treatment Referral to ophthalmologist Digital massage of globe by MD Supportive environment Possible IV therapy Anticoagulants tPA Low-molecular weight Dextran Admission and possibly surgery

Surgical Ocular Emergencies

Corneal Abrasion Partial or complete removal of an area of epithelium of the cornea Most common eye injury seen in the ER Common causes: FB, contact lenses, exposure to UV light

Corneal Abrasion Symptoms/Assessment Mild to severe pain Foreign body sensation Photophobia Normal to slightly decreased visual acuity Injected conjunctiva Tearing Abnormal Fluorescein stain

Corneal Abrasion Treatment Education Topical analgesic Topical ophthalmic antibiotic Tight patch to affected eye for 12-24 hours Education Follow-up care Proper patching techniques Instillation of meds S/S of infection Use extra precaution with activities requiring depth perception

Extraocular Foreign Body Can enter as a result from hammering, grinding, working under cars, or working above the head “Something going into my eye” Metal, sawdust, dust particles Metal can form a rust ring on the cornea

Extraocular Foreign Body Symptoms/Assessment Pain Foreign body sensation Tearing Redness Normal to slightly abnormal visual acuity Fluorscein stain abnormal FB visualized Diagnostics Magnifying lens Fluorescein stain Slit-lamp

Extraocular Foreign Body Treatment Topical anesthetic Topical anesthetic inhibit wound healing and are toxic to corneal epithelium Gentle irrigation with NS FB removal with moist cotton swab, needle, eye spud if irrigation Patch both eyes to reduce unsuccessful consensual movement Possible admission

Extraocular Foreign Body Education Instillation of meds Patching techniques Follow-up care Provide preventative information

Retinal Detachment Separation of the retinal layers, with accumulation of serous fluid or blood between the sensory retina and the retinal epithelium Leads to decrease blood supply and oxygen to the retina Most common cause: degenerative changes in the retina or vitreous body of the elderly Sports direct head trauma

Retinal Detachment Symptoms/Assessment Diagnostic Gradual or sudden deterioration of vision unilaterally Cloudy, smoky vision Flashing lights Curtain or veil over visual field No pain Diagnostic Fundoscopy Visual acuity Slit-lamp exam

Retinal Detachment Treatment Referral to ophthalmologist Patch both eyes or shielding to reduce eye movement Bed rest, lying quietly Supportive and calm environment Admission or transfer

Orbital fracture Fracture of the orbit without a fracture of the orbital rim Common cause: blunt trauma from fist, ball, or nonpenetrating object These fractures are associated with entrapment and ischemia of nerves or penetration into a sinus

Orbital fracture Symptoms/Assessment Hx of blunt trauma Diplopia Facial anesthesia Pain Sunken appearance of the eye Limited vertical eye movement EOM abnormal Crepitus Periorbital edema, hematoma, ecchymosis Subconjunctival hemorrhage Look for other injuries

Orbital fracture Diagnostics Visual acuity Fundoscopy CT scan X-rays Orbits Facial Waters’ Treatment/Education Ophthalmological consult Analgesics Antibiotics Ice pack Refrain from blowing nose Follow-up care Possible admission or surgery

Chemical Burns True ocular emergency Distinction between acid and alkali exposure must be made Immediate irrigation

Chemical Burns Symptoms/Assessment Pain Variable degree of visual loss Chemical exposure Corneal whitening

Chemical Burns Treatment Referral to ophthalmology Irrigate with NS for 20-30 minutes Administer cycloplegic Analgesics Eye patch Td

Hyphema Blood in the anterior chamber from the iris bleeding Usually result of blunt trauma Significant risk of secondary bleeding in 3-5 days with outcomes poor

Hyphema Symptoms/Assessment Blurred vision Blood tinged vision Pain Visualized blood in anterior chamber at bottom of iris Assess for other associated injuries

Hyphema Treatment/Education Have patient sit upright or bedrest with HOB 30° Patch or shield both eyes Diuretics to decrease intraocular pressure Refrain from taking aspirin Refer to ophthalmologist Admission

Eyelid Laceration Symptoms/Assessment Treatment/Education MOI Visual disturbance Laceration Protrusion of fat Upper lid does not raise Assess for ocular injuries Bleeding Treatment/Education Stop bleeding: Avoid direct pressure on the eye Surgical repair Topical analgesic Td Wound care S/S of infection Follow-up

Globe Rupture Ocular Emergency Penetrating or perforating injury

Globe Rupture Symptoms/Assessment MOI Direct visualization of FB Blunt Penetrating Sudden visual impairment or loss Pain Asymmetry of globe Extrusion of aqueous or vitreous humor Direct visualization of FB Irregularities in pupillary borders Diagnostics CT scan MRI Orbit films Slit-lamp exam

Do Not Remove IT! Globe Rupture Treatment Ophthalmological referral Do not open eye Keep patient in Semi-Fowlers position Patch/shield affected both eyes IV analgesics IV antibiotics Td Calm, supportive environment Admission/Surgery If impaled object: Secure it. Do Not Remove IT!