Ocular Emergencies Abdulrahman Al-Muammar College of Medicine King Saud University

What Should you learn from this lecture? Early recognition of ocular emergencies will determine final visual outcomes -Penetrating trauma -Non penetrating injury -Corneal ulcer -Chemical burns -Acute angle closure glaucoma -Orbital cellulitis -Retinal detachment Proper history Full assessment Initial managementReferral planning

Bright light Pupil examination -Is it round? -Is it regular? -Is it reactive? Visual acuity -Determine light perception -Appreciate hand motion -Count fingers -See things across the clinic -Visual acuity chart Ocular movement Lid -Ecchymosis -Laceration -Foreign body -Orbital asymmetry Conjunctiva -Chemosis -Hemorrhage -Foreign body -Uveal prolapse Cornea -Haze -Pus -Iris prolapse -Fluorescein staining -Seidel test Anterior chamber -Blood -Pus -Flat

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

Corneal Ulcer Prompt diagnosis of the etiology by doing corneal scrapingPrompt diagnosis of the etiology by doing corneal scraping Treatment with appropriate antimicrobial therapy are essential to minimize visual lossTreatment 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 cautionAny redness occurring for patients who wear contact lens should be managed with extreme caution Remove lensRemove lens Rule out corneal infectionRule out corneal infection Antibiotics for gram negative organismsAntibiotics for gram negative organisms Do not patchDo not patch Follow up with ophthalmologist in 24 hoursFollow up with ophthalmologist in 24 hours

Chemical Injuries A vision-threatening emergencyA vision-threatening emergency The offending chemical may be in the form of a solid, liquid, powder, mist, or vapor.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…..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 surfaceCan range in severity from mild irritation to complete destruction of the ocular surface ManagementManagement Instill topical anestheticInstill topical anesthetic Check for and remove foreign bodiesCheck for and remove foreign bodies

Chemical Injuries Immediate irrigation essential, preferably with saline or Ringer’s lactate solution, for at least 30 minutesImmediate 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)Irrigation should be continued until neutral pH is reached (i.e.,7.0) Instill topical antibioticInstill topical antibiotic Frequent lubricationsFrequent lubrications Oral pain medicationOral pain medication Refer promptly to ophthalmologistRefer promptly to ophthalmologist

Corneal and Conjunctival Foreign Bodies ManagementManagement Instill topical anestheticInstill topical anesthetic Removal of the foreign bodyRemoval of the foreign body Topical antibioticTopical antibiotic Treat corneal abrasionTreat corneal abrasion

Acute Angle Closure Glaucoma Result from peripheral iris blocking the outflow of fluidResult from peripheral iris blocking the outflow of fluid

Acute Angle Closure Glaucoma Present with pain, redness, mid-dilated pupil with decrease vision and coloured haloes around lightsPresent with pain, redness, mid-dilated pupil with decrease vision and coloured haloes around lights Severe headache or nausea and vomitingSevere headache or nausea and vomiting Intraocular pressure is elevatedIntraocular pressure is elevated Can cause severe visual loss due to optic nerve damageCan cause severe visual loss due to optic nerve damage Medical Tx and peripheral laser iridotomy will be curative in most casesMedical Tx and peripheral laser iridotomy will be curative in most cases

Acute Angle Closure Glaucoma Medical Tx and peripheral laser iridotomy will be curative in most casesMedical Tx and peripheral laser iridotomy will be curative in most cases

Preseptal Cellulitis

Lid swelling and erythemaLid swelling and erythema Visual acuity,motility, pupils, and globe are normalVisual acuity,motility, pupils, and globe are normal

Preseptal Cellulitis EtiologyEtiology Puncture woundPuncture wound LacerationLaceration Retained foreign body from traumaRetained foreign body from trauma Vascular extension, or extension from sinuses or another infectious site ( e.g.,dacryocystitis, chalazion)Vascular extension, or extension from sinuses or another infectious site ( e.g.,dacryocystitis, chalazion) OrganismsOrganisms Staph aureus – Streptococci- H.influenzaeStaph aureus – Streptococci- H.influenzae

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

Orbital Cellulitis PainPain Decreased visionDecreased vision Impaired ocular motility/double visionImpaired ocular motility/double vision Afferent pupillary defectAfferent pupillary defect Conjunctival chemosis and injectionConjunctival chemosis and injection ProptosisProptosis Optic nerve swellingOptic nerve swelling

Orbital Cellulitis Management:Management: AdmissionAdmission Intravenous antibioticsIntravenous antibiotics Nasopharynx and blood culturesNasopharynx and blood cultures Surgery maybe necessarySurgery maybe necessary

Orbital Cellulitis

Retinal Detachment SymptomsSymptoms Flashes, floaters, a curtain or shadow moving over the field of visionFlashes, floaters, a curtain or shadow moving over the field of vision Peripheral and/ or central visual lossPeripheral and/ or central visual loss

Retinal Detachment

Ocular trauma

Hyphema Can occur with blunt or penetrating injuryCan occur with blunt or penetrating injury Blood in the anterior chamberBlood in the anterior chamber

Hyphema Can lead to high intraocular pressureCan lead to high intraocular pressure Detailed history (Sickle cell)Detailed history (Sickle cell) ManagementManagement Bed restBed rest Topical steroidTopical steroid Topical cycloplegicTopical cycloplegic Antifibrinolysis agents (Tranexamic acid)Antifibrinolysis agents (Tranexamic acid) Surgical evacuationSurgical evacuation

Ruptured globe Suspect a ruptured globe if:Suspect a ruptured globe if: Bullous subconjunctival hemorrhageBullous subconjunctival hemorrhage Uveal prolapse (Iris or ciliary body)Uveal prolapse (Iris or ciliary body) Irregular pupilIrregular pupil HyphemaHyphema Vitreous hemorrhageVitreous hemorrhage Lens opacityLens opacity Lowered intraocular pressureLowered intraocular pressure

If globe ruptured or laceration is suspected Stop examinationStop examination AntiemeticsAntiemetics Shield the eyeShield the eye Systemic antibioticsSystemic antibiotics Give tetanus prophylaxisGive tetanus prophylaxis Refer immediately to ophthalmologistRefer immediately to ophthalmologist

Orbital Fractures -Periorbital edema -Ecchymosis + tenderness to palpation along the inferior orbital rim -Subconjunctival hemorrhage -Enophthalmos -Hypoesthesia of the cheek and upper gum -Subcutaneous emphysema -Palpable step-off of the orbital rim

Thank you