Ocular emergencies Erin Moorcones, RN, MSN

The Eye

Anatomy and physiology The eyes are protected by bony structures, eyelids, and sclera. Lacrimal glands secrete tears, which continuously bathe eye to decrease friction and remove minor irritants. Light enters the eye through the cornea, passes through the lens, and reflected off the retina. Amount of light entering is controlled by iris.

Patient Assessment A potential threat to vision is triaged as emergent, whereas patient with a reddened eye with no potential for vision loss could be non-urgent.

Visual Acuity Visual acuity should be done on all patients with eye or visual complaint, unless patient sustained chemical exposure to eye where irrigation is priority.

Pupil Examination Includes assessment of shape, size, and reactivity. Up to 20-25% of population have unequal pupils ( physiologic anisocoria- pupils vary <1mm with brisk reaction to light) as a normal finding. FYI- * oval pupil may indicate tumor or retinal detachment * teardrop pupil suggest ruptured globe- teardrop pointing to rupture site

Anterior segment Composed of sclera, conjunctiva , cornea, anterior chamber, iris, lens and ciliary body. Inspect clearness of cornea. Ocular movement- assess cranial nerves

General strategy HPI * Pain- PQRST * Appearance of eye- swelling, redness, aysmmetry * changes in vision, tearing, itching, discharge PMH- *pre-existing disease- DM, htn, sicle cell * ocular- lenses, surgery, glaucoma, eye disease Pysch/ social- * work environment, school, hobbies

Assessment General- loc, vs, hygiene, level of distress Inspection- visual acuity- vital sign of opthamology, eyelid adnexa, surface, tearing, discharge, EOM’s, hazy cornea. Palpation- intraocular pressure, warmth of surrounding tissues. Diagnostic- culture,CRP, coags. Imaging- CT, MRI, xrays.

Consultation required Chemical burns, lid lacerations, glaucoma, retinal detachment, orbital fracture, hyphema, cellulitus

Age related considerations May need to use picture chart, children may not notice gradual vision loss, look for STD’s in newborns with eye complaints PEARLS_ patientce, infants may need to be restrained, red eye is not always infectious, consider corneal abrasion in crying infants

Geriatric considerations Vision gradually dimishes until age 70, then rapidly Decreased accuracy of visiontesting Eye accomodation decreases with age Older adults complain of eye dryness. Cataracts more common with advancing age. 1 in 3 adults age 80 affected. More liekly to experience glaucoma, detached retna, retinal bleeding PEARLS- * health referrals * Protected environment

Infections Lid infections- Hordeolum- infection of eyelash oil gland. Apply warm compress 4 times a day with ophthalmic antibiotics

Chalazion Internal hordeolum caused by chronic inflammation. Patient presents with several weeks of painless, localized swelling. If it affects vision may have I&D No localized swelling

Herpes Simplex of eye Symptoms- watery discharge, burning, and foreign body

Conjunctivitis Inflammatory condition of membrane that lines the eyelids and covers exposed surface of sclera. Causes- bacteria, virus, chlamydia/gonorrhea, chemical burns, foreign bodies,exposure to irritants.

Assessment HPI -redness, abrupt onset, unilateral/bilateral, pain, FB sensation, discharge, edema, itching, burning, fever PMH -URI, contact with others, medications (steroids-may exacerbate infections, esp w/Herpes infections) Objective data- -distress, visual acuity, cornea, pupil, conjunctiva, chemosis, discharge, eyelid edema

Assessment Diagnostic- culture, fluorescein stain, gram stain Interventions - cleanse eyelids (inner-outer) - warm compress, bacterial/cool compress, viral - medications - education

Anterior Uveitis/Iritis Uveitis-inflammation of one or all the parts of the uveal tract (iris, ciliary body, choroid) S/S- intense unilateral pain, conjunctivitis, edema, lacrimation, photophobia. Posterior uveitis (choroiditis)- rare, seen in CMV infections associated with AIDS

Treatment- Warm compress, dark enviornment Topical steroid, Eye rest f/u referral

Periorbital/Orbital Cellulitis Acute redness and swelling of the eye and surrounding area. Determine if involvement is superficial, or extension into globe and deeper structures. s/s- swollen, erythematous eyelid, with mild/diffuse conjunctival infection. In young children may be associted with paranasal sinusitis. Orbital celulits, serious, involves eye.

Key assessment pieces S/S- Temperature, Decreased pupillary reflexes Diagnostic- CT, culture, CBC, LP Treatment- warm compress, excision of abscess, antibiotics, F/u

Glaucoma Peak age 55-70. gradual increase in pressure and sudden dilation of pupil

S/S- red eye, pain, HA, bluured vision, photophobia, n/v. Physical exam- decreased visual acuity, cornea-hazy, steamy, intraocular pressure 40-80, hardness to globe with palpation, Diagnostic- slit-lam, tonometry Treatment- beta antagonists, pilocarpine droops

Acute angle-closure glaucoma PACG increases with age and more common in women and eskimo’s and those of Asian decent. Estimated to be the cause of 46% of all cases of irreversible blindness. S/S- severe eye pain, fixed or slightly dilated pupil, foggy appearing cornea, severe headache, complaints of halo’s around lights, diminished peripheral vision Treatment- must decrease IOP quickly

Central retinal artery occlusion Sudden, painless, unilateral loss of vision caused by thrombus/emboli Prompt recognition and intervention w/I 1-2 hrs of onset necessary. Treatment- referral ocular hypotensive drops carbon gas for vasodilation

Trauma Blunt trauma- caused by MVC, fall, assault Symptoms include- ecchymosis, redness Resolution of bruising usually resolves in 2 weeks.

Orbital fractures Involve the orbital floor and orbital rim Orbital floor fracture, aka blowout fracture. Direct trauma causes increase in IOP. Orbital contents may herniate into the maxillary or ethmoid sinuses. Diagnosis- by observation of periorbital ecchymosis, subconjunctival hemorrhage, periorbital edema, upward gaze and diplopia. CT or MRI Orbital fractures not emergency unless visual injury or globe injury present

Hyphema Bleeding into anterior chamber of eye. Occurs when blood vessels of the iris rupture and leak into the clear aqueous fluid of anterior chamber. Symptoms- pain, photophobia, blurred vision Treatment- beta blockers to dec IOP, mydriatic agents, steroids, pain mgmt, anti emetics

Subconjunctival hemorrhage Harmless eye condition that is usually triggered by sneeze, cough, Valsalva. Symptoms- painless, bright red flat patch Usually reabsorbs in 2-3 weeks

Globe rupture Major ocular emergency, results from blunt or penetrating trauma. s/s unusually deep or shallow anterior chamber, altered light perception, hyphema, pupil assumes tear drop shape. Eye drops should not be used and aggressive pain management is crucial to prevent or decrease expulsion of introcular contents. Anti emetics should be used

Foreign Body Most common is dust particle Organic FB have higher incidence of infection. Metallic FB leave rust ring unless removed w/I 12 hours Inert FB do not cause infection, but higher risk for penetration

Superficial Trauma Corneal abrasion- FB such as contact scratches, abrades, or denudes optical epithelium. Damage to cornea exposes corneal nerves causing tearing, eyelid spasms, and pain. May need topical analgesic to get visual acuity. Assess eyelids to ensure no FB. Diagnosis with fluorescein.

Corneal laceration Ophthamolgy consult required. Present similar to corneal abrasion

Burns Chemical Burns- from acids, alkalis. copious irrigation needed. Thermal burns- usually affects eyelids. Radiation burns- UV or infrared Chemical burns- require at least 2l and 30 minutes of irrigation. Should receive topical anlagesics and abx.