Dr Mahmood Fauzi Assist. Prof Ophthalmogy Ocular Emergencies Dr Mahmood Fauzi Assist. Prof Ophthalmogy

Eye Anatomy Illinois EMSC

Ocular Emergencies Lid Lacerations Foreign Bodies Corneal Lacerations/Abrasions Penetrating Injuries and Contusions of the Eyeball Globe Rupture Burns of the Eye Chemical injuries Orbital Fractures Acute congestive glaucoma

Facts to elicit from the history General Are both eyes affected or only one? Time of onset Recurrence Events preceding the current state Recent history of ocular disease or surgery Other diseases, specifically cardiac, vascular, or autoimmune Family history for ocular problems Current medications or recent changes to medications Changes in vision (lost, blurred, or decreased vision; diplopia, sudden or gradual) Visual acuity before the current event Other symptoms (pain, nausea, vomiting)

Emergency Eye Examination Visual acuity External examination Pupils Extraocular muscles Injection Discharge Preauricular lymphadenopathy (usually viral) Follicles (usually viral; chronic – r/o chlamydial) Papillae (usually allergy) Follicles Papillae

Emergency Eye Examination, Cornea-fluorescein test Evert lid IOP Confrontational fields Ophthalmoscopy Lab & radiology testing Treat/refer/consult Pearls Infection control Chemical injuries, irrigation STAT, Morgan lens Compare both eyes Iritis

Corneal Abrasion

Corneal Abrasions History of scratching the eye Symptoms: Foreign body sensation Pain Tearing Photophobia

Corneal Abrasions Treatment: Topical antibiotic Pressure patch over the eye Refer to ophthalmologist

Corneal Ulcer Corneal ulcer occur secondary to lid and conjunctival inflammation but is often due to trauma or contact lens wear Bacterial, viral, fungal or parasitic

Corneal Ulcer Ocular pain, redness and discharge with decrease vision and white lesion on the cornea

Corneal Ulcer Prompt diagnosis of the etiology by doing corneal scraping Treatment with appropriate antimicrobial therapy are essential to minimize visual loss

Contact lens wearer Any redness occurring for patients who wear contact lens should be managed with extreme caution Remove lens Rule out corneal infection Antibiotics for gram negative organisms Do not patch Follow up with ophthalmologist in 24 hours

Chemical Injuries A vision-threatening emergency The offending chemical may be in the form of a solid, liquid, powder, mist, or vapor. Can occur in the home, most commonly from detergents, disinfectants, solvents, cosmetics, drain cleaners…..

Chemical Injuries Can range in severity from mild irritation to complete destruction of the ocular surface Management Instill topical anesthetic Check for and remove foreign bodies

Chemical Injuries Immediate irrigation essential, preferably with saline or Ringer’s lactate solution, for at least 30 minutes

Chemicals Injuries Irrigation should be continued until neutral pH is reached (i.e.,7.0) Instill topical antibiotic Frequent lubrications Oral pain medication Refer promptly to ophthalmologist

Burns Chemical Burns Heat Burns Light Burns Call EMS Irrigate continuously, gently Heat Burns Apply a loose, moist dressing Light Burns Symptoms delayed - bilateral Cover both eyes with dark patches Illinois EMSC

Alkali Burn of the Cornea Illinois EMSC

Corneal and Conjunctival Foreign Bodies History of trauma Foreign body sensation-Tearing

Corneal and Conjunctival Foreign Bodies Management Instill topical anesthetic Removal of the foreign body Topical antibiotic Treat corneal abrasion

Fluorescein Stain

Linear epithelial defects suggestive of foreign body under the eye lid KEY ED MANAGEMENT: If patient history worrisome for foreign body, but nothing is visualized on initial exam, EVERT the eyelids. Many foreign bodies become lodged in upper lid and are not visible on initial exam.

Blunt trauma Superficial FB – flourescein stain fractures, hemorrhage, or damage to the globe or adnexa Fx sharp edges that can cause entrapment or damage to the muscle or globe Retrobulbar hemorrhage - analogous to compartment syndrome elevated intraocular and extraocular pressures, causing permanent damage Hyphema warrants suspicion for penetrating trauma, orbital fracture, acute glaucoma, or retinal detachment

control swelling and pressure CT for fracture, retrobulbar hemorrhage, laceration, or intraocular foreign body control swelling and pressure Cold compresses Nasal decongestants Lateral canthotomy tetanus prophylaxis

Orbital Floor or Blow-Out Fracture Trauma Orbital floor – most common Symptoms Diplopia Restricted eye movement Hyposthesia Air accumulation Sunken eye View globe inferior Crepitus – nose blowing

Orbital Floor or Blow-Out Fracture Pearls Broad-spectrum po antibiotic Cold compress – ice pack Nasal decongestants Nose blowing Retinal detachment – coup, counter-coup CAT scan of orbit Refer always, same day Opthalmology, ENT

Preseptal Cellulitis

Preseptal Cellulitis Lid swelling and erythema Visual acuity ,motility, pupils, and globe are normal

Preseptal Cellulitis Etiology Puncture wound Laceration Retained foreign body from trauma Vascular extension, or extension from sinuses or another infectious site ( e.g.,dacryocystitis, chalazion) Organisms Staph aureus – Streptococci- H.influenzae

Preseptal Cellulitis Management: Warm compresses Systemic antibiotics CT sinuses and orbit if not better or +ve history of trauma

Orbital Cellulitis Pain Decreased vision Impaired ocular motility/double vision Afferent pupillary defect Conjunctival chemosis and injection Proptosis Optic nerve swelling

Orbital Cellulitis Management: Admission Intravenous antibiotics Nasopharynx and blood cultures Surgery maybe necessary

Orbital Cellulitis

Penetrating/lacerating trauma damage or destroy anatomic structures compromise protective outer layers, increasing the risk of infection Sympathetic ophthalmia <2%

Penetrating Injury r/o rupture eye protected – fox shield CT If rupture no further exam - EUA eye protected – fox shield CT systemic antibiotics initiated- NOT topical NPO, time of last meal tetanus prophylaxis

Lid repair Avoid retraction of lid margin Check canilicular system Gray line to gray line Check canilicular system Remove FB Tetanus prophylaxis

“Eyelids don’t have fat” 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

Ruptured globe Penetrating trauma leads to corneal or scleral disruption and extravasation of intraocular contents. Can lead to: Irreversible visual loss Endophthalmitis -inflammation of the intraocular cavities

Ruptured Globe Signs and symptoms: pain, decreased vision hyphema loss of anterior chamber depth “tear-drop” pupil which points toward laceration severe subconjunctival hemorrhage completely encircling the cornea. Diagnosis: positive Seidel’s test, clinical exam.

Ruptured Globe Management Stop the examination Cover with metal eye shield or styrofoam cup. DO NOT PATCH. Consult ophthalmology immediately Do not perform tonometry. CT head and orbit to evaluate for concomitant facial/orbital injury. NPO, tetanus Antibiotics: Cefazolin + ciprofloxacin provides good coverage. Antiemetics and analgesics decrease risk of Valsalva or movement which could increase IOP.

Acute Angle Closure Glaucoma (AACG) - Diagnosis History: Acute onset, higher risk in far-sighted Symptoms: Pain Halos (around lights) Visual loss (usually peripheral) Nausea/vomiting Signs: Conjunctival injection Corneal edema Mid-dilated, fixed pupil  IOP (normal: 10 – 20 mmHg) An attack of acute angle-closure glaucoma in predisposed persons can occur as a result of dim lighting or use of certain medications (e.g., dilating drops, anticholinergics, antidepressants). Medications such as sulfa derivatives and topiramate (Topamax) can cause swelling of the ciliary body and secondary angle closure. www.eyemd.com

Glaucoma - Pathophysiology Aqueous humor produced by ciliary body, enters ant. chamber, drains via trabecular meshwork at angle to enter canal of Schlemm In AACG, iris obstructs trabecular meshwork by closing off angle Optic nerve damage 2° IOP www.eyesearch.com

Acute Angle Closure Glaucoma Medical Tx 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 Ophtho referral: Laser peripheral iridectomy

Eye Injury Prevention Education Require use of protective eyewear Investigate causes of eye injuries and remove hazards Collaborate with school staff to reduce incidence of injury Illinois EMSC

“Your job is to make discussions.” “If two people agree on everything, then only one of them is thinking.” - Senator Sam Rayburn “Your job is to make discussions.” Pierre Rouzier, M.D.

A “Red Eye” Patient presents whose right eye is red, painful and very sensitive to light. When you shine the penlight in her left eye, it causes her pain in the right (affected) eye. What diagnosis does it suggest?

Another red eye A three-year old child presents with erythema and swelling around the left eye. The Pediatric resident says, “It’s periorbital cellulitis; start the kid on antibiotics and send him home.” Are you comfortable with that?

Poked in the eye! A young boy presents to the ER after having been poked in the eye by another student. He is being seen by a resident who is just about to measure the child’s intra-ocular pressure when you yell “STOP!!!!!!” Why are you so uptight? Now what should you do?

Drain cleaner in the eye A patient comes to the ER having gotten some drain cleaner in her eye and it's causing her a lot of pain. The triage nurse tells her the wait to be seen is 1 hour and the patient becomes irate and starts to leave. You happen to overhear this conversation What should you do? Why? Treatment? How long?

Baseball versus eye A young male presents to the ER after having been hit in the eye with a baseball. He says, "I keep seeing double when I look up". Diagnosis? Pathophysiology? Treatment?

FB sensation A young male presents to the ER with foreign body sensation to this left eye. He was pounding a nail and felt something get into his eye. You examine patient and find that other than some photophobia, his exam is normal. You are about to discharge him when the attending says, hold on just a minute. What could you have possibly missed? How do you make the diagnosis?

Positive Seidel’s You carefully examine the patient and place fluorescein in his eye. You see the fluorescein streaming. What is this called? What does it signify? Where could be the likely truama?

Red Eye Danger Signs Decreased visual acuity Pain Ciliary flush Pupillary asymmetry Irregular corneal light reflex Corneal infiltrate Photophobia Trauma

Emergency Eye Examination Visual acuity External examination Pupils Extraocular muscles Injection Discharge Preauricular lymphadenopathy (usually viral) Follicles (usually viral; chronic – r/o chlamydial) Papillae (usually allergy) Follicles Papillae

Ocular Injection Conjunctival injection Conjunctivitis Ciliary (circumcorneal) injection Keratitis including corneal abrasions, foreign bodies Iritis Glaucoma

Ocular Injection Segmental injection Episcleritis Injected pinguecula Embedded foreign body Marginal keratitis Phlyctenular limbal keratoconjunctivitis

Non- Vision Threatening Red Eye Conjunctivitis Stye (hordeolum) Chalazion Blepharitis Conjuctival foreign bodies

Subconjunctival Hemorrhage Pearls No trauma normal vision, no pain, self-limited, benign Trauma r/o intraocular injury Worse day 2? BP Treatment? ASA? When to refer Concommitant trauma

Stye (hordeolum) Infection Treatment WC P.o pain medication Usually staph aureus Treatment WC P.o pain medication Topical antibiotics Systemic antibiotics lid cellulitis or pain?

Cyst (chalazion) Inflammation Treatment Pearls WC Near lid margin R/o steroid injection Pearls R/o rosacea malignancy w/recurrence Systemic doxycycline

Cyst (chalazion) When to refer Not resolving in 2 – 3 weeks Cosmetic Vision Lid margin

Vision-Threatening Red Eye & Emergencies Corneal abrasions Conjunctival & corneal foreign bodies Keratitis Iritis Hyphema Blow-out fracture Retinal detachment Papilledema

4th Generation Fluoroquinolones Options: Zymar, Allergan (gatifloxacin) Vigamox, Alcon (moxifloxacin) Benefits: lower incidence of resistance may shorten infection more effective for gram + potency, concentration active – pseudomonas aerunginosa permeability, solubility comfort

Thank you