1. Ocular emergencies
Erin Moorcones, RN, MSN

2. The Eye

3. 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.

4. 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.

5. 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.

6. 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

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

8. 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

9. 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.

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

12. 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

13. 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

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

15. 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

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

17. 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.

18. 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

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

20. 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

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

22. 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.

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

24. Glaucoma
Peak age gradual increase in pressure and sudden dilation of pupil

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

33. 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

35. 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.

36. Corneal laceration Ophthamolgy consult required.
Present similar to corneal abrasion

37. 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.