ocular emergencies. ocular emergencies medical conjunctivitis iritis periorbital cellulitis ...
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Ocular Emergencies
OCULAR EMERGENCIES
Medical Conjunctivitis 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
Assessment
History / MOITime of occurrenceTreatment before arrivalAbnormal eye appearanceVisual acuity
Snellen’s Visual Fields Finger count
Assessment
TearingItchingDischarge Medical History
Ocular Systemic Medication
Always use contralateral eye for comparison
Assessment
Spasms of eyelidLesions, FB, Penetrating woundsPupilsEOMPosition and alignment of eye
Assessment
Conjunctiva and sclera for color and inflammation
Edema of lids, conjunctive, and/or corneaBloodOpaque, gray-white area of corneaHazy cornea
Assessment
PalpationIntraocular pressure: Do not do if
there is concern regarding globe
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
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
Diagnostics
Direct ophthalmoscopeTonometryFluorescein stainingSlit-lamp examLaboratory
Cultures CBC Coags
Diagnostics
RadiologyCT scanSoft tissue/orbit films for foreign
bodyFacial bonesSkull films
Priorities
ABCsPrevent further damagePrevent or minimize complicationsControl painRelieve anxiety or apprehensionEducation
Consultation Criteria
Penetrating ocular trauma
Chemical burns of the eye
Severe lid laceration
Glaucoma
Central retinal artery occlusion
Retinal detachment
Orbital fractureHyphemaPeriorbital
cellulitis
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
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
Age-related PearlsGeriatric
Decreased accommodation to distances
Decreased lacrimal secretions Cataracts: at age 80 1 in 3
are affectedMore likely to experience
glaucoma, detached retina, and retinal bleeds
Medical Ocular Emergencies
Conjunctivitis
Inflammation of the conjunctivaCauses:
bacterial/viral inflammation allergies Chlamydia chemical burns FB flash burns Irritants URI
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
Conjunctivitis
Treatment 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
IritisInflammatory process that includes the iris
and sometimes the ciliary bodyPredisposing conditions:rheumatic disease,
and syphillis
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
Iritis
Treatment/Education Analgesics NSAIDs Cycloplegics to
paralyze ciliary muscle and spasms
Darkened environment
Rest eyes Warm compresses Shield eyes or dark
glasses Follow-up
Periorbital Cellulitis
Infection of the cells around the eyesA major ophthalmological emergency and is
potentially life threateningMay occur after trauma such as laceration or
an insect bitePneumococcal, staphylococcal, streptococcal
Periorbital CellulitisSymptoms/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
Periorbital Cellulitis
Treatment/Education Referral to
ophthalmologist Bedrest IV therapy IV antibiotics Warm compresses
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 SituationMay lead to irrecoverable blindness
GlaucomaSymptoms/Assessment
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
Glaucoma
Treatment/Education Referral to
ophthalmologist Analgesic Antiemetic Pilocarpine eyedrops Osmotic diuretic Supportive and
informative environment
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
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
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
Surgical Ocular Emergencies
Corneal AbrasionPartial or complete removal of an area of
epithelium of the corneaMost common eye injury seen in the ERCommon causes: FB, contact lenses,
exposure to UV light
Corneal Abrasion
Symptoms/Assessment Mild to severe pain Foreign body sensation Photophobia Normal to slightly
decreased visual acuity Injected conjunctiva Tearing Abnormal Fluorescein
stain
Corneal Abrasion
Treatment Topical analgesic Topical ophthalmic
antibiotic Tight patch to affected
eye for 12-24 hours
Education Follow-up care Proper patching
techniques Instillation of meds S/S of infection Use extra precaution
with activities requiring depth perception
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 particlesMetal can form a rust ring on the cornea
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
Extraocular Foreign Body
TreatmentTopical 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
Extraocular Foreign Body
Education Instillation of
meds Patching
techniques Follow-up care Provide
preventative information
Retinal DetachmentSeparation 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
Retinal Detachment
Symptoms/Assessment 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
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
Orbital fractureFracture of the orbit without a fracture of
the orbital rimCommon cause: blunt trauma from fist, ball,
or nonpenetrating objectThese fractures are associated with
entrapment and ischemia of nerves or penetration into a sinus
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
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
Chemical Burns
True ocular emergencyDistinction between acid and alkali exposure
must be madeImmediate irrigation
Chemical Burns
Symptoms/Assessment Pain Variable degree of
visual loss Chemical exposure Corneal whitening
Chemical Burns
Treatment Referral to
ophthalmology Irrigate with NS for
20-30 minutes Administer
cycloplegic Analgesics Eye patch Td
Hyphema
Blood in the anterior chamber from the iris bleeding
Usually result of blunt traumaSignificant risk of secondary bleeding in 3-5
days with outcomes poor
Hyphema
Symptoms/Assessment Blurred vision Blood tinged vision Pain Visualized blood in
anterior chamber at bottom of iris
Assess for other associated injuries
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
Eyelid Laceration
Symptoms/Assessment 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
Globe Rupture
Ocular EmergencyPenetrating or perforating injury
Globe Rupture
Symptoms/Assessment MOI
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
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!