Ocular Emergencies Ocular Emergencies Abdullah Alfawaz, MD,FRCSAbdullah Alfawaz, MD,FRCS

Ass. Prof. Cornea/Uveitis service Ass. Prof. Cornea/Uveitis service

College of Medicine, King Saud UniversityCollege of Medicine, King Saud University

Ocular EmergenciesOcular Emergencies

General Emergancies:General Emergancies:• Corneal ulcerCorneal ulcer• UveitisUveitis• Acute angle closure Acute angle closure

glaucomaglaucoma• Orbital cellulitisOrbital cellulitis• EndophthalmitisEndophthalmitis• Retinal detachmentRetinal detachment

Orbital/Ocular trauma:Orbital/Ocular trauma:• Corneal abrasionCorneal abrasion• Corneal and conjunctival Corneal and conjunctival

foreign bodiesforeign bodies• HyphemaHyphema• Ruptured globeRuptured globe• Orbital wall fractureOrbital wall fracture• Lid LacerationLid Laceration• Chemical injuryChemical injury

Corneal UlcerCorneal Ulcer

Corneal ulcer occur secondary to lid Corneal ulcer occur secondary to lid and conjunctival inflammation but it is and conjunctival inflammation but it is often secondary to trauma or contact often secondary to trauma or contact lens wearlens wear

Bacterial, viral, fungal or parasiticBacterial, viral, fungal or parasitic

Corneal UlcerCorneal Ulcer

Ocular pain, redness and discharge Ocular pain, redness and discharge with decrease vision and corneal with decrease vision and corneal opacity.opacity.

Corneal UlcerCorneal UlcerManagement: Management:

1.1. Prompt diagnosis of the etiology by doing Prompt diagnosis of the etiology by doing corneal scraping.corneal scraping.

2.2. Treatment with appropriate antimicrobial Treatment with appropriate antimicrobial therapy is essential to minimize visual loss.therapy is essential to minimize visual loss.

3.3. Then treat the inflammatory processThen treat the inflammatory process

4.4. Promote healing and treat the primary cause Promote healing and treat the primary cause if present (e.g. lid deformity, dryness)if present (e.g. lid deformity, dryness)

Contact lens wearerContact lens wearerAny redness occur for patients who wear contact Any redness occur for patients who wear contact lens should be managed with extreme cautionlens should be managed with extreme caution

Remove lensRemove lens

Rule out corneal infection (i.e corneal ulcer)Rule out corneal infection (i.e corneal ulcer)

gram negative organisms, fungi and Acanthembea gram negative organisms, fungi and Acanthembea are common causative organismsare common causative organisms

Do not patchDo not patch

Close Follow upClose Follow up

UveitisUveitisInflammation of the uveal tissue (iris, ciliary body, or Inflammation of the uveal tissue (iris, ciliary body, or choroid), retina, blood vessels, optic disc, and choroid), retina, blood vessels, optic disc, and vitreous can be involved.vitreous can be involved.EtiologyEtiology

IdiopathicIdiopathicInflammatory diseasesInflammatory diseases

• HLA B27, Ankylosing spondylitis, IBD, Reiter’s syndrome, HLA B27, Ankylosing spondylitis, IBD, Reiter’s syndrome, Psoriatic arthritisPsoriatic arthritis

• Sarcoidosis, Behcet’s, Vogt-Koyanagi-Harada SyndromeSarcoidosis, Behcet’s, Vogt-Koyanagi-Harada SyndromeInfectiousInfectious

• Herpes virusHerpes virus• ToxoplasmosisToxoplasmosis• TuberculosisTuberculosis• SyphilisSyphilis

UveitisUveitis

UveitisUveitis

UveitisUveitis

ManagementManagementIdentify possible causeIdentify possible causeTopical steroidTopical steroidTopical cycloplegicTopical cycloplegicSystemic immunosuppressive medicationSystemic immunosuppressive medication

• SteroidSteroid• CyclosporineCyclosporine• MethotrexateMethotrexate• Azathioprine Azathioprine • CyclophosphamideCyclophosphamide

Immunomodulating agentsImmunomodulating agents• Infliximab (Anti TNF)Infliximab (Anti TNF)

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

Result from peripheral iris blocking the Result from peripheral iris blocking the outflow of fluidoutflow of fluid

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

Present with pain, redness, mid-dilated pupil Present with pain, redness, mid-dilated pupil with decrease vision and coloured haloes with decrease vision and coloured haloes around lightsaround lightsSevere headache or nausea and vomitingSevere headache or nausea and vomitingIntraocular pressure is elevatedIntraocular pressure is elevatedCan cause severe visual loss due to optic Can cause severe visual loss due to optic nerve damagenerve damageMedical Tx and peripheral laser iridotomy will Medical Tx and peripheral laser iridotomy will be curative in most casesbe curative in most cases

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

Medical Tx and peripheral laser Medical Tx and peripheral laser iridotomy will be curative in most casesiridotomy will be curative in most cases

Preseptal CellulitisPreseptal Cellulitis

Preseptal CellulitisPreseptal Cellulitis• Lid swelling and erythemaLid swelling and erythema• Visual acuity ,motility, pupils, and globe are Visual acuity ,motility, pupils, and globe are

normalnormal

Preseptal CellulitisPreseptal Cellulitis

EtiologyEtiologySkin woundSkin woundLacerationLacerationRetained foreign body from traumaRetained foreign body from traumaVascular extension, or extension from Vascular extension, or extension from sinuses or another infectious site sinuses or another infectious site ( e.g.,dacryocystitis, chalazion)( e.g.,dacryocystitis, chalazion)OrganismsOrganisms• Staph aureus – Streptococci- H.influenzaeStaph aureus – Streptococci- H.influenzae

Preseptal CellulitisPreseptal Cellulitis

Management:Management:Warm compressesWarm compresses

Systemic antibioticsSystemic antibiotics

CT sinuses and orbit if not better or +ve CT sinuses and orbit if not better or +ve history of traumahistory of trauma

Orbital CellulitisOrbital 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 CellulitisOrbital Cellulitis

Management:Management:AdmissionAdmission

Intravenous antibioticsIntravenous antibiotics

Nasopharynx and blood culturesNasopharynx and blood cultures

Surgery maybe necessarySurgery maybe necessary

Orbital CellulitisOrbital Cellulitis

EndophthalmitisEndophthalmitis

Potentially devastating complication of Potentially devastating complication of any intraocular surgeryany intraocular surgery

Any patient in the early postoperative Any patient in the early postoperative period (within 6 weeks of surgery) c/o period (within 6 weeks of surgery) c/o pain or decrease vision should be pain or decrease vision should be evaluated immediatelyevaluated immediately

EndophthalmitisEndophthalmitis• ManagementManagement

– Vitreous sample for cultureVitreous sample for culture– Intravitreal antibiotics injection plus topical antibioticsIntravitreal antibiotics injection plus topical antibiotics

Retinal DetachmentRetinal Detachment

SymptomsSymptomsFlashes, floaters, a curtain or shadow Flashes, floaters, a curtain or shadow moving over the field of visionmoving over the field of vision

Peripheral and/ or central visual lossPeripheral and/ or central visual loss

Retinal DetachmentRetinal Detachment

Corneal AbrasionCorneal Abrasion

Corneal AbrasionsCorneal Abrasions

History of scratching the eyeHistory of scratching the eye

Symptoms:Symptoms:Foreign body sensationForeign body sensation

PainPain

TearingTearing

PhotophobiaPhotophobia

Corneal AbrasionsCorneal Abrasions

Treatment:Treatment:Topical antibioticTopical antibiotic

Pressure patch over the eyePressure patch over the eye

Refer to ophthalmologistRefer to ophthalmologist

Chemical InjuriesChemical Injuries

A vision-threatening emergencyA vision-threatening emergency

The offending chemical may be in the The offending chemical may be in the form of a solid, liquid, powder, mist, or form of a solid, liquid, powder, mist, or vapor.vapor.

Can occur in the home, most commonly Can occur in the home, most commonly from detergents, disinfectants, solvents, from detergents, disinfectants, solvents, cosmetics, drain cleaners…..cosmetics, drain cleaners…..

Chemical InjuriesChemical Injuries

Can range in severity from mild irritation Can range in severity from mild irritation to complete destruction of the ocular to complete destruction of the ocular surfacesurface

Management:Management:Irrigate with clean waterIrrigate with clean water

Instill topical anestheticInstill topical anesthetic

Check for and remove foreign bodiesCheck for and remove foreign bodies

Chemical InjuriesChemical Injuries

Immediate irrigation essential, preferably Immediate irrigation essential, preferably with saline or Ringer’s lactate solution, for with saline or Ringer’s lactate solution, for at least 30 minutesat least 30 minutes

Chemicals InjuriesChemicals Injuries

Irrigation should be continued until neutral Irrigation should be continued until neutral pH is reached (i.e.,7.0)pH is reached (i.e.,7.0)

Instill topical antibioticInstill topical antibiotic

Frequent lubricationsFrequent lubrications

Oral pain medicationOral pain medication

Enhance healingEnhance healing

Corneal and Conjunctival Foreign Corneal and Conjunctival Foreign BodiesBodies

• History of traumaHistory of trauma• Foreign body sensation-TearingForeign body sensation-Tearing

Corneal and Conjunctival Foreign Corneal and Conjunctival Foreign BodiesBodies

ManagementManagementInstill topical anestheticInstill topical anesthetic

Removal of the foreign bodyRemoval of the foreign body

Topical antibioticTopical antibiotic

Treat corneal abrasionTreat corneal abrasion

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

HyphemaHyphema

Can lead to high intraocular pressureCan lead to high intraocular pressureDetailed history (Sickle cell)Detailed history (Sickle cell)ManagementManagement

Bed restBed restTopical steroidTopical steroidTopical cycloplegicTopical cycloplegicAntifibrinolysis agents (Tranexamic acid)Antifibrinolysis agents (Tranexamic acid)Surgical evacuationSurgical evacuation

Ruptured GlobeRuptured Globe• Suspect a ruptured globe if:Suspect a ruptured globe if:

– Severe blunt traumaSevere blunt trauma– Sharp objectSharp object

Ruptured globeRuptured globe

Suspect a ruptured globe if:Suspect a ruptured globe if:Bullous subconjunctival hemorrhageBullous subconjunctival hemorrhageUveal prolapse (Iris or ciliary body)Uveal prolapse (Iris or ciliary body)Irregular pupilIrregular pupilHyphemaHyphemaVitreous hemorrhageVitreous hemorrhageLens opacityLens opacityLowered intraocular pressureLowered intraocular pressure

Ruptured GlobeRuptured Globe

Bullous subconjunctival hemorrhageBullous subconjunctival hemorrhage

Ruptured GlobeRuptured Globe

Uveal prolapse (Iris or ciliary body)Uveal prolapse (Iris or ciliary body)

Ruptured GlobeRuptured Globe

• Irregular pupilIrregular pupil

Ruptured GlobeRuptured Globe

• Intraocular foreign bodyIntraocular foreign body

If globe ruptured or laceration is If globe ruptured or laceration is suspectedsuspected

• Stop examinationStop examination

• Shield the eyeShield the eye

• Give tetanus prophylaxisGive tetanus prophylaxis

• Refer immediately to ophthalmologistRefer immediately to ophthalmologist

Orbital FracturesOrbital Fractures• Assess ocular motilityAssess ocular motility• Assess sensation over cheek and lipAssess sensation over cheek and lip• Palpate for bony abnormalityPalpate for bony abnormality

Lid LacerationLid Laceration– Can result from sharp or blunt traumaCan result from sharp or blunt trauma– Rule out associated ocular injuryRule out associated ocular injury

Break TimeBreak Time