1. Ocular Urgencies and Emergencies
Mindy J. Dickinson, OD
Midwest Eye Care, PC
Omaha/Council Bluffs

2. Objectives Triage Procedure Emergent vs Urgent
Using symptoms to help decide urgency
Overview of acute eye problems
What symptoms cue you in to problem
What history is important
How soon should patient be seen
What does the problem look like

3. Triage Screening process
Assess patient’s problem to determine if and how soon patient needs seen
Done over phone or if patient walks into clinic
Need to decide if problem is emergent, urgent, or routine

4. Triage Questions should ask: 1) Chief complaint or symptoms ?
got something in eye, matted shut, red, tearing, pain, blurred vision, loss of vision, double vision, floaters/flashes
2) When did it happen ? How long how long has problem been going on ?
3) Severity ? Worsening ?
4) Have they tried any treatments already ?
Irrigated the eye, old antibiotic they had at home, artificial tears
5) Did someone tell them to come in ?
Dr in ER, their PCP, etc

5. Triage Must get patient’s information Be professional, calm
Name
Date and time of call
Telephone number patient can be reached at
May want to get idea how long they can be reached at that number so we get back to them in time
Be professional, calm
Exhibit care and concern

6. Triage Urgency usually greater when problem is Severe Worsening
Recent onset
Affecting vision
Referred by another doctor
Patient is very concerned

7. Triage Emergent Situation Urgent Situation Routine Situation
Requires immediate action
Come to clinic or go to ER same day
Urgent Situation
Requires patient be seen within hours
Routine Situation
Requires patient to be seen within few days to a week

8. Using Symptoms to help you…
Redness
Discharge
Foreign Body Sensation
Itching
Burning
Eye Lid Swelling “edema”
Light Sensitivity “photophobia”
Pain
Changes in Vision or something blocking Vision

9. Causes of Redness Blepharitis Conjunctivitis Episcleritis/Scleritis
Dryness/Exposure
Trichiasis/Entropion
Uveitis
Subconjunctival Hemorrhage
Contact Lens related problems
Corneal Ulcer
Corneal Abrasion/Recurrent Corneal Erosion
Foreign Body
Chemical Burns/Welding Burns
Acute Glaucoma

10. Discharge Causes of Discharge Tearing, thick mucus, stringy
Green or yellow
Lots or just a little
Causes of Discharge
Conjunctivitis (bacterial, viral, allergic)
Blepharitis
Hordeolum (stye)
Corneal trauma – scratch, foreign body, ulcer, chemical burn contact lens related problem
Dry Eye Disease

11. Foreign Body Sensation
Scratchy
“gravel in eye”, “eyelash in eye”
Causes of FBS
Foreign body in cornea or conjunctiva
Trichiasis (eye lash rubbing on eye)
Corneal or Conjunctival Abrasion
Dry Eye Disease
Conjunctivitis
Contact Lens Intolerance

12. Itching/Burning Usually less urgent Causes Blepharitis * Allergy *
Conjunctivitis *
Dry Eye Disease *
Contact Lens intolerance
Keratitis (corneal inflammation)
Inflamed pinguecula or pterygium

13. Swelling “edema” Causes of lid edema Eyelid swelling
Conjunctival swelling “chemosis”
Causes of lid edema
Conjunctivitis
Corneal disease (foreign body, abrasion, ulcer)
Hordeolum (stye)
Preseptal Cellulitis/Cellulitis
Blunt Trauma
Contact Dermatitis
Chemical exposure/burn
Herpes Zoster (shingles)

14. Light Sensitivity “Photophobia”
Indicates eye inflamed
Corneal and/or Anterior Chamber involvement
More urgent !!
Causes of Photophobia
Corneal trauma – abrasion, ulcer, foreign body, CL overwear
Keratitis
Herpes Simplex Keratitis
Uveitis
Dry Eye Disease

15. PAIN More severe the pain = more urgent !!!
Grading scale 1 to 10 (10 is worst ever)
Superficial, sharp pain
Deep, achy, throbbing pain
On eye movement?
Constant vs intermittent?
History of trauma?
More severe the pain = more urgent !!!

16. Vision Affected or Unaffected If affected = more urgent!!
Hazy, blurred, missing half of vision, black spot in middle
Floaters, flashes of light, “curtain”
Double vision
Constantly reduced vs comes and goes
May be associated with pain or be painless
Even if not affected now… is vision threatened ?

17. Vision-Threatening vs. Not Vision-Threatening
Conjunctivitis
Episcleritis
Blepharitis
Trichiasis
Dry Eye Syndrome
Subconjunctival Hemorrhage
Hordeolum/Chalazion

18. Potentially Vision Threatening Emergencies that HURT
Corneal Ulcer
Corneal Abrasion
Chemical Burn
Foreign body
Herpes Simplex
Herpes Zoster
Uveitis
Cellulitis
Trauma
Hyphema
Orbital Fracture
Ruptured Globe
Acute Glaucoma
These are all associated with pain, redness, &/or photophobia
All are EMERGENCIES!!

19. PAINLESS Loss or Threats to Vision
No pain or redness, but may have…
New Floaters
Flashes of Light
Curtain in Vision
Significant reduction in overall vision
“Smudge” in central vision
Half of vision missing
Vision dimmed out, went black, now its back
Double vision (diplopia)
All are EMERGENCIES !!
Posterior Vitreous Detachment
Retinal Tear
Vitreous Hemorrhage
Retinal Detachment
Retinal Vascular Occlusion
Amaurosis Fugax
Wet Macular Degeneration
Macular Edema
Optic Nerve Swelling
Cranial Nerve Palsy
Impending Stroke

20. Other Helpful Information…
Do they Wear Contacts ?
Sleep in lenses? Are lenses old?
More urgent !!
Tell patient to take lenses out !!
Trauma ?
Previous Treatments tried ?
If not working or problem worsening = more urgent
If haven’t tried anything, may be able to make some suggestions (artificial tears, cold or warm compresses)

21. Other Helpful Information…
Ocular history – if any of these, likely more urgent
Corneal abrasion - risk of recurrent corneal erosion
Corneal ulcer
Herpes simplex
Uveitis
Trichiasis
Recent Posterior Vitreous Detachment
High Myopia
Lattice Degeneration
s/p Ocular Surgery or Laser
Macular Degeneration

22. Other Helpful Information
Ocular History
History of a chronic problem like Blepharitis or Dry Eye disease may reduce urgency
Ask patient what they have been trying to do for relief and what is and isn’t working
May be able to make suggestions over the phone or at least to get patient by until exam time in a few days

23. Other Helpful Information
Referral from another doctor
Schedule based on need requested by other doctor
If urgent request, need to get worked in regardless of schedule
Get Dr’s name, phone number, address, fax
Patient’s level of anxiety or concern
Even though may be less urgent problem, good care may mean seeing patient to ease concern

24. When in doubt … Ask your doctor!!
Would rather error on side of caution and see sooner
Dr may know more about patient’s history to recommend sooner or later appointment
Even if less urgent (ie. broken glasses), Dr’s schedule may allow for sooner appointment and therefore better customer service

25. Overview of Acute Eye Problems
Objectives:
Familiar with name of problem
Familiar with what problem might look like
Symptoms associated with problem
Urgency of examination

26. Subconjunctival Hemorrhage
Broken blood vessel causing blood to collect under conjunctiva
Symptoms
Confluent Redness
No discharge, pain
No change in vision

27. Confluent Redness in Subconjunctival hemorrhage

28. Subconjunctival Hemorrhage
History of trauma ?
Use of blood thinners ?
Coumadin, Plavix, Aspirin
High dose of ibuprofen, naproxen, vitamin E
Recurrent ?
NOT URGENT
may be able to triage over phone
Patient may need Dr for reassurance

29. Conjunctivitis Inflammation of conjunctiva
Injection of bulbar and palpebral conjunctiva
DISCHARGE !

30. Types of Conjunctivitis
Bacterial *
Viral *
Allergic *
Blepharoconjunctivitis (associated with Blepharitis)
Keratoconjunctivis Sicca (Dry Eye Syndrome)
Contact Lens Related
Chlamydial
Gonococcal
Vernal/Atopic

31. Symptoms of Conjunctivitis
Mild to moderate redness
Scratchy, Burning, Stinging, Sticky, Itchy
DISCHARGE
Tearing, Watery, Stringy, Mucoid, Purulent (LOTS)
“eyelids matted shut upon awakening”
Little to no affect on vision
If affected, usually “hazy”, intermittent
Little to no pain
Perhaps hx of exposure to someone else with “pink eye” or recent cold symptoms

32. Mucopurulent Conjunctivitis

33. Viral Conjunctivitis

34. Conjunctivitis associated with Contact Lenses

35. Sub-Epithelial Infiltrates in Viral Conjunctivitis

36. Conjunctivitis Usually Self-Limiting !!!
Going to get better no matter what
Even without treatment, most will resolve in days
More are viral than bacterial
If vision affected, more pain, or more severe symptoms should see same day
Also if not getting better, could be misdiagnosed see urgently

37. Conjunctivitis – Treatment
Antibiotic drops (if bacterial)
Anti-allergy drops (if allergic)
Preservative-Free Artificial tears (chilled tears good for inflammation and very soothing)
Cold compresses
Oral NSAID (ibuprofen)
Good hand washing
Discontinue contact lens use (at least temporarily)

38. Keratoconjunctivitis Sicca - “Dry Eye Syndrome”
Poor tear film covering eye
Due to not enough production or evaporating too quickly
Leads to exposure, mucus build up, and inflammation of cornea and conjunctiva
Symptoms
Burning, stinging, tearing, fluctuations in vision, foreign body sensation, stringy mucus

39. Dry Eye Syndrome CHRONIC problem
symptoms can vary from mild to severe
Mild urgency – see same day or next day if not already diagnosed
If already diagnosed but worsening, then a few days okay

40. Tear Break Up in Dry Eye Syndrome

41. Eye Lid Disease - Blepharitis
Inflammation of lid margin
Crusting along lashes
Clogging of Oil Glands
(meibomian glands)
“Red-rimmed” eyes
Chronic recurrent issue
Symptoms:
Burning, itchy, mattering, crusty, foreign body sensation, red

42. Blepharitis
Anterior blepharitis
Posterior blepharitis

43. Blepharitis Chronic Disease with good days and bad days
Patient’s history may help you know how soon patient needs soon
What treatment are they already on
Mild to Moderate Urgency – 24 to 72 hours

44. Trichiasis Misdirected eyelashes rubbing on eye Recurrent
Scratchy, foreign body sensation, tearing, mild discomfort
See within 24 hrs

45. Entropion Eye lid turned inward Lashes rub on eye
Scratchy, foreign body sensation, tearing, mild discomfort
See in hours
Tx with surgery
may tape lid out or use ung to get by until surgery

46. Hordeolum “stye” Blocked eyelid gland Localized infection/inflammation
Eyelid is very tender and red with localized swelling
See in hours if vision not affected and eye still open
If vision affected or cannot open eye = emergent

47. Chalazion Not Urgent, may be seen in few days to week
Old blockage of gland in eyelid
No longer inflamed
Non-tender, non-red bump in eyelid that “been there for a while”
Not Urgent, may be seen in few days to week
Ask if did hot packs
Warn likely won’t be removed that day of first office visit

48. Preseptal Cellulits vs Cellulitis
Spreading of infection / inflammation into surrounding eyelid tissue or into orbital socket and into brain
May start as stye or with trauma
Symptoms:
SIGNIFICANT eyelid swelling
Red, hot skin
Pain, Fever
In orbital cases, causes decreased vision, pain on eye movement, afferent pupil defect, proptosis (bulging of eye)
EMERGENCY!!

49. Preseptal Cellulitis second to Trauma

50. Orbital Cellulitis

51. Allergic Reaction of Eyelids
Lid edema
Scaling of eyelid skin
Red, warm skin
Painless!!
Itchy
Mild urgency
24 to 36 hours

52. Epicleritis vs Scleritis - inflammation of episcleral or scleral layers of eye
EPISCLERITIS
not serious
Eye is mildly pink
No discharge
Vision not affected
None to minimal pain
URGENT – 24 hours
SCLERITIS
very serious
Very Red but no discharge
Photophobic
Very Painful – can wake pt from sleep, cause decreased appetite, pain may radiate into temple or brow
Vision may be decreased
EMERGENT – right away

53. More Superficial Injection in EPISCLERTIS

54. Episcleritis

55. Scleritis

56. Corneal Foreign Body Metal embedded in cornea
Often get Rust Ring and surrounding edema
Tearing, pain, light sensitivity, redness
Hx of grinding metal
See right away!

57. Corneal Abrasion History of trauma Significant pain and tearing
Photophobia
Blurred vision
EMERGENCY
– see right away !

58. Recurrent Corneal Erosion
Corneal epithelium sloughs off without any new history of scratching it
Usually happens upon awakening in morning
Have history of either
corneal abrasion
anterior basement membrane dystrophy
Very painful
Tearing, red, swollen lid ** see that day

59. Corneal Ulcer
Epithelial defect with infiltration by immune cells – may be inflammatory or infectious
Non-light passing opaque lesion
Symptoms are severe
PAIN, redness, tearing, photophobia
Important history – CL wearer?
Sleep in CL? Swim in CL? How old are CL?

60. Corneal Ulcers

61. Corneal Ulcers If suspect ulcer, see ASAP!!
Hypopyon may be present (pus in anterior chamber)
If suspect ulcer, see ASAP!!
Patient may need cultures, seen daily until showing improvement

62. Corneal Ulcers

63. Herpes Simplex Dendritic Keratitis
Cold sore virus causing ulceration of cornea
Very classic pattern of staining – dendritic “tree-branching” lesions
VISION THREATENING!
Severe Pain, Redness, Photophobia
Unilateral
Can be recurrent

64. Herpes Simplex EPITHELIAL Keratitis

65. Herpetic Keratitis Often misdiagnosed as pink eye or corneal ulcer
If pink eye that not getting better – could be suspicious
Likely to recur
If have this history, bring patient in same day

66. Herpes Simplex STROMAL Keratitis
Due to immune system reactivating in response to virus, not the virus itself in the cornea
Cornea edema, anterior chamber reaction, but no ulcer
++ Pain, Photophobia, Reduced vision
See ASAP, especially if hx of HSV

67. Herpes Zoster = “Shingles”
Related to chicken pox
Sores on skin on 1/2 of body, torso or face – usually forehead and eyelids
Usually preceded by pain or tingling while combing hair or along eyebrow
Can cause eyelid sores, conjunctivitis, corneal plaques, or uveitis
If immunocomprimised, can also cause retinitis or neuritis

69. Shingles
Patient usually comes as a consult from family practice doctor
If reduced vision or red eye, need to see ASAP
If just confirming no ocular involvement, likely okay to see within 24 hours

70. Uveitis Inflammatory reaction in anterior chamber of eye
Also called “iritis” or “iridocyclitis”
May be idiopathic or due to underlying systemic disorder
Often initially misdiagnosed as “pink eye” by PCP
Symptoms:
Redness, Photophobia, Deep Throbbing/Aching pain “headache behind eye”

71. Uveitis Potentially threatening to vision
Can cause cataract or glaucoma
May involve retina, optic nerve, macula
Often recurrent and patients can tell when it comes back – so if history of uveitis – see same day
Based on symptoms alone, but also history, see same day

72. Hyphema Blood in anterior chamber due to blunt trauma
Immediate risk of pressure spike, rebleed, retinal detachment, traumatic optic nerve damage

73. Hyphema Need to see these patients right away
Put on bed rest until blood clears
Long term risk of traumatic cataract and glaucoma

74. Penetrating Injury History of Trauma Excess tearing Extreme Pain
True EMERGENCY!!
When use fluorescein dye, see a stream of aqueous seeping out and washing it away
“seidel postive”

75. Penetrating injury Manipulate globe as little as possible!!
Do not check IOP
Place shield over eye
Requires immediate Surgical Referral

76. Sutured corneal laceration

77. Chemical Burn – Acidic or Alkali
POTENTIALLY VISION THREATENING!
1st thing to tell them to do over the phone is IRRIGATE, IRRIGATE, IRRIGATE !
( before ever coming in to the office)
At least minutes
if wearing contact lens, irrigate for 5 minutes or so, then remove lens and continue to irrigate for another 25 minutes
Then come to office or go to ER right away !

78. Chemical Burns Mild = Red eye (good prognosis)
Severe = White eye (poor prognosis)
Expect to see
eyelid edema
burns of periocular skin
conjunctival chemosis & hyperemia
conjunctival abrasion
corneal staining – mild irritation to complete loss of skin
If severe – get blanching of conjunctiva – no blood/oxygen getting to eye or cornea – BAD !!

79. ACUTE Glaucoma Sudden Significant Increase in IOP
High IOP (usually 50 or greater)
Due to blockage of drainage system
Angle closure, inflammatory, neovascular
Hx of high hyperopia, narrow angles, proliferative diabetic retinopathy, central retinal vein occlusion
Symptoms (SEVERE)
Pain, Headache (brow ache), Nausea, Vomiting, Red Eye, Blurred Vision

80. Acute Glaucoma See ASAP Work in ahead of all other patients
Need to get pressure down right away to prevent permanent vision loss (from central retinal artery occlusion – not from glaucoma damage to nerve)

81. Acute Glaucoma

82. Acute Glaucoma
Shallow anterior chamber, red eye, hazy cornea, mid-dilated pupil

83. Posterior Vitreous Detachment
Vitreous gel liquifies with age
Eventually pulls away from retina
May or may not tear a blood vessel or the retina when pulls away
~10% of retinal tear
FLASHES OF LIGHT
NEW FLOATERS

84. Posterior Vitreous Detachment
If patient denies decreased vision or curtain/veil in vision, may wait until next day
If decreased vision, lots of “little dots in vision” or “curtain/veil” in vision, or following history :
Highly myopic (near-sighted)
Lattice Degeneration
s/p cataract surgery
Recent posterior vitreous detachment (PVD)
*** then see same day, ASAP

85. Retinal Tear May or may not be associated with retinal detachment
Painless
May or may not have a decrease in VA
If blood in eye going to be blurry

86. Retinal Detachment “Rhegamotogenous” means due to tear(s) in retina
Fluid in eye seeps out and breaks down seal to hold retina on
May be partial or total

87. Retinal Detachment Sudden painless loss of vision
May start as flashes/new floaters
“Curtain” or “Veil” in vision or portion of side vision missing

88. Retinal Detachment If Macula still on = good VA If Macula already off
Emergency surgery
If Macula already off
= bad VA
Surgery within few days to week

89. Flashes of Light – Retina or Migraine
Ocular Migraine
One eye
Pinpoint or lightning bolts that come from same direction
Last a split second, but may repeat many times over hours to days
No associated headache
EMERGENCY
Both eyes
Usually swirling lights, perhaps colored, altered side vision
Last 5-30 minutes and then over
May or may not be followed by headache
Not Emergent (other than to ease patients and dr’s minds)

90. Vein Occlusion Painless loss of vision
Often associated with long-standing diabetes and hypertension
Hard-walled arteries push down and compress squishy-walled veins
Risk of neovascularization and glaucoma
May be central vein or a branch vein
If blood is not spilt into macula then patient may have no symptoms

91. Central Retinal Vein Occlusion (CRVO)
Blockage along main vein draining eye
Blood backs up and spills out into retina
Swelling of optic nerve
Vision very poor (20/200 or worse)
See same day

92. Branch Retinal Vein Occlusion

93. Arterial Occlusion Sudden painless loss of vision
“Vision kept getting dimmer and dimmer”
Clot or thick blood blocks flow of blood into eye
If temporary blockage and then passes, only get intermittent loss or dimming of vision
“Amaurosis fugax”
Need to consider underlying cause to prevent other problems like a stroke!

94. Central Retinal Artery Occlusion
Blockage of main artery into eye
No blood getting in = no oxygen
Very limited time to get blood to eye or tissue suffocates and dies
EMERGENCY!

95. Central Retinal Artery Occlusion

96. Branch Retinal Artery Occlusion
Plaque breaks off from either carotid artery or heart valve and travels to eye
Gets trapped in small arteriole of eye
Usually leaves a long-term blind spot in area where there was no blood flow

97. Vitreous Hemorrhage Blood leaking into vitreous due to: Trauma
Retinal tear
Leakage from new blood vessels growing in the retina that are not supposed to be there
Proliferative diabetic retinopathy
Neovascularization after central or branch vein occlusion
Wet macular degeneration where blood breaks out of retina and into vitreous
Tumor in retina

98. Vitreous Hemorrhage

99. Vitreous Hemorrhage Usually painless, sudden loss of vision
Emergent - See same day
May look like “lots of dots” in vision or may be “hand motion” vision if blood is more dense
Sometimes so much blood we cannot even see in to tell where it is coming from
B-scan ultrasound to see retina

100. Exudative “Wet” Macular Degeneration
Blood or fluid leaking into macula from abnormal vessels
1 in 10 “dry” become “wet”

101. Wet Macular Degeneration
Symptoms:
Rapid onset of visual loss
Central blind spot
Distortion of straight lines (Amsler Grid)
No pain
+/- History of Dry AMD
See same day!

102. Macular Degeneration
Central scotoma
Amsler Grid

103. Exudative Macular Degeneration
Lots of new therapies exist, but more effective when done right away
Injections (Avastin, Lucentis, Eyelea)
Need to get these consults into retinal clinic schedules as soon as possible
Often need fluorescein angiography and/or macular OCT

104. Optic Neuritis Swelling of optic nerve Unilateral or bilateral
Symptoms
Slow deterioration of vision over hours to days
Orbital pain, especially on eye movements
Loss of color vision or light intensity
See same day

105. Optic Nerve Edema Vision loss may be mild “smudge” to severe (20/400)
+/- headache
+/- neck pain
+/- fatigue while chewing
+/- scalp tenderness
+/- malaise “sick feeling”

106. Optic Nerve Edema May be due to: Infection Multiple scleroris
Inflammatory disease
Severe “malignant” hypertension
Lack of oxygen “ischemic”
NAION
AION – “Giant cell arteritis” – “temporal arteritis”
Tumor along optic nerve or in brain
Pseudotumor (intracranial hypertension)

107. Chief Complaint of “Diplopia”
When gathering history on this patient, ask:
1) Happening with one eye or with both eyes open ?
2) Constant or intermittent ?
3) How long has it been going on ?
4) Do the images appear side by side, up and down, or diagonal from one another?
5) Recent trauma, headache, stroke, long term vascular disease (hypertension, diabetes)?
6) Any other muscle weakness?
7) Have they already had prism in their glasses?
** if not previously established cause for diplopia, then see same day!!

108. Causes of Diplopia Palsy of Extraocular Muscle
Cranial Nerve 3, 4, 6
Sudden onset
May resolve over 3 month period, may last forever
May due to vascular disease, trauma, aneurysm, tumor, increased pressure in brain
Trauma that restricts an extraocular muscle
Blow-out fracture of orbit
Usually have surgery to fix
Decompensating Phoria
Have had eye misalignment since young, but muscles no longer can compensate
Gradual cause with sudden observation
Orbital Disease
Thyroid Eye Disease “Grave’s Disease”
Orbital Mass

109. Questions? Thank you!