1. Ocular Emergencies

2. 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

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

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

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

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

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

8. 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

9. 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

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

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

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

13. 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

14. 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

15. 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

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

17. Medical Ocular Emergencies

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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

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

27. 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

28. 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

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

30. 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

31. 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

32. 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

33. Surgical Ocular Emergencies

34. 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

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

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

37. 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

38. 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

39. 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

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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

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

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

49. Chemical Burns Treatment Referral to ophthalmology
Irrigate with NS for minutes
Administer cycloplegic
Analgesics
Eye patch Td

50. 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

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

52. 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

53. 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

54. Globe Rupture
Ocular Emergency
Penetrating or perforating injury

55. 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

56. 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!