Ocular Emergencies

Pisit Preechawat, MD

Department of Ophthalmology, Ramathibodi Hospital

Ocular AnatomyOcular Anatomy

1. Frontal bone

2. Zygomatic bone

3. Maxillary bone

4. Sphenoid bone

5. Ethmoid bone

6. Lacrimal bone

7. Palatine bone

1

2 3

4 5

67

Bony Components of OrbitBony Components of Orbit

Size 30 x 40 x 45 mm Size 30 x 40 x 45 mm

Paranasal SinusParanasal Sinus

Ocular AnatomyOcular Anatomy

Orbicularis Oculi

Ocular AnatomyOcular Anatomy

Ocular AnatomyOcular Anatomy

Ocular AnatomyOcular Anatomy

Extraocular MusclesExtraocular Muscles

Optic NerveOptic Nerve

Venous SystemVenous System

Ocular EmergenciesOcular Emergencies

TraumaTrauma

Non - traumaNon - trauma

Blunt traumaBlunt trauma

Penetrating traumaPenetrating trauma

Retinal arterial Perforation Orbital cellulitis occlusion Ruptured Orbital injury Chemical burns Acute glaucoma Corneal ulcer

Sudden congestion Corneal abrasion proptosis Hyphema

Intraocular FB Retinal detachment Macular edema

( Immediately ) ( Within a few hours ) ( Within one day )

Acute Eye ConditionsAcute Eye Conditions

EmergencyEmergency Very UrgentVery Urgent UrgentUrgent

Ocular condiitons requiring immediate

treatment

Acute Angle-Closure Glaucoma

Central Retinal Artery Occlusion

Orbital Cellulitis

Cavernous Sinus Thrombosis

Endophthalmitis

Retinal Detachment

Toxic Causes of blindness

Nontraumatic Ocular Emergencies

Acute Dacryocystitis

Acute Dacryoadenitis

Acute Hordeolum

Preseptal cellulitis

Spontaneous subconjunctival hemorrhage

Conjunctivitis

Bacterial corneal ulcer

Viral keratoconjunctivitis

Acute hydrops of the cornea

Hyphema

Uveitis ( iritis & iridocyclitis )

Vitreous hemorrhage

Retinal hemorrhage

Central retinal vein occlusion

Optic neuritis

Ocular EmergenciesOcular Emergencies

Ocular burns and trauma

Ocular Burn

Alkali Burns

Acid Burns

Thermal Burns

Burns Due to Ultraviolet Radiation

Mechanical Trauma to the Eye

Penetrating or Perforating injuries

Blunt Trauma to the Eye, Adnexa,& Orbit

1. Ecchymosis of the Eyelids

2. Lacerations of the Eyelids

3. Orbital hemorrhage

4. Fracture of the Ethmoid bone

5. Blowout Fractures of the Floor of the Orbit

6. Corneal Abrasions

7. Corneal & Conjunctival Foreign Bodies

Ocular EmergenciesOcular Emergencies

Eye ExaminationEye Examination

Visual acuity Visual acuity

External Eye : orbit, periorbital skin, eyelidsExternal Eye : orbit, periorbital skin, eyelids

Confrontation visual fieldsConfrontation visual fields

Ocular motilityOcular motility

Anterior SegmentAnterior Segment

ConjunctivaConjunctiva

CorneaCornea

Anterior chamberAnterior chamber

Iris Iris

LensLens

Pupils : RAPDPupils : RAPD

Eye ExaminationEye Examination

A dilated pupil makes it easier to see the optic A dilated pupil makes it easier to see the optic nerve, macula, and retinanerve, macula, and retina

- 1% tropicamide ( Mydriacyl )- 1% tropicamide ( Mydriacyl )

- 2.5% phenylephrine ( Neo-Synephrine )- 2.5% phenylephrine ( Neo-Synephrine )

PanOptic Ophthalmoscope

Indirect Ophthalmoscope

Fundus ExaminationFundus Examination

Digital palpationDigital palpation

Schiotz tonometerSchiotz tonometer

Intraocular Pressure MeasurementIntraocular Pressure Measurement

Ocular TraumaOcular Trauma

Closed Globe Open Globe

Burn

Contusion

Laceration Laceration

Penetrating Perforating

Rupture

CausesCauses

• Trauma, HypertensionTrauma, Hypertension

• Valsava pressure spikesValsava pressure spikes

• SpontaneousSpontaneous

No treatmentNo treatment

Resolve within 2 weeksResolve within 2 weeks

Subconjunctival HemorrhageSubconjunctival Hemorrhage

Pain , photophobia , FB sensation, tearing

Conjunctival injection, swollen eyelid

Epithelial staining defect with fluorescein

Corneal AbrasionCorneal Abrasion

Topical cycloplegia, ATB ointment Pressure patching for 24 hours

Searching for conjunctival foreign body

Don’t apply PP if there is a significant risk of infection.

Corneal AbrasionCorneal Abrasion : Management: Management

Corneal UlcerCorneal Ulcer

Hypopyon

Eye Shield

No patching

Topical antibiotics

Ophthalmologist referral

Conjunctival Foreign BodiesConjunctival Foreign Bodies

Corneal foreign body with rust ring

Rust ring

Corneal Foreign BodiesCorneal Foreign Bodies

Remove the FB under the best magnification

Evert the eyelid to rule out additional FB

Treat resulting corneal abrasion

Referral to ophthalmologist, next day

Residual rust ring

Corneal Foreign BodiesCorneal Foreign Bodies

Corneal Foreign Body RemovalCorneal Foreign Body Removal

Disruption of blood vessels in the iris or ciliary body Blood in anterior chamber

Traumatic HyphemaTraumatic Hyphema

Grade Grade  Size of HyphemaSize of Hyphema

00 No layered bloodNo layered bloodcirculating red blood cells onlycirculating red blood cells only

I I  Less thanLess than 1/3 1/3

II II  1/31/3 to to 1/21/2

III III  1/21/2 to less than total to less than total

IV IV  Total Total

Traumatic Hyphema : ClassificationTraumatic Hyphema : Classification

Traumatic HyphemaTraumatic Hyphema

Elevate the patient’s head

Bed rest

1% atropine one drop 3-4 times daily

1% prednisolone acetate one drop 3-4 times daily

If the globe is intact, measure IOP

Reduce IOP

Ophthalmology consult

Traumatic Hyphema : ManagementTraumatic Hyphema : Management

Rebleeding can occur 3 to 5 days later in 30%

Uncontrolled glaucoma or blood stained cornea

requires anterior chamber “wash out”

Traumatic Hyphema : ManagementTraumatic Hyphema : Management

Sharp or blunt traumaSharp or blunt trauma

R/O associated ocular injuryR/O associated ocular injury

Remove superficial FBRemove superficial FB

Rule out deeper FBRule out deeper FB

Give tetanus prophylaxis Give tetanus prophylaxis

Lid LacerationsLid Lacerations

Tear lid margin

Full Thickness Lid LacerationsFull Thickness Lid Lacerations

- Gray line

- Lash line

- Mucocutaneous junction

Laceration of lower eyelid margin Post-operative result following a primary repair

Lid Margin RepairLid Margin Repair

Refer to ophthalmologist if there are Refer to ophthalmologist if there are associated ocular injuriesassociated ocular injuries

Lid LacerationsLid Lacerations

Ruptured globeRuptured globe

Lacrimal drainage systemLacrimal drainage system

Levator aponeurosisLevator aponeurosis

Medial canthal tendonMedial canthal tendon

Tissue loss ( > 1/3 )Tissue loss ( > 1/3 )

Lid LacerationsLid Lacerations with tear canaliculiwith tear canaliculi

Canalicular RepairCanalicular Repair

Tear Canthal TendonTear Canthal Tendon

Woman with tearing and medial canthal Woman with tearing and medial canthal asymmetry after the repair of a laceration asymmetry after the repair of a laceration sustained during a domestic assaultsustained during a domestic assault

Penetrating / Ruptured Globe Penetrating / Ruptured Globe

Corneal or scleral lacerationsCorneal or scleral lacerations

Hypotony (not always present)Hypotony (not always present)

Severe chemosis & hemorrhageSevere chemosis & hemorrhage

Intraocular contents may be outside the globeIntraocular contents may be outside the globe

Limitation of extraocular motilityLimitation of extraocular motility

Shallow anterior chamberShallow anterior chamber

Irregular pupilIrregular pupil

Irregular pupilIrregular pupil

Penetrating / Ruptured Globe Penetrating / Ruptured Globe

Ruptured globe caused by golf ball

Penetrating / Ruptured Globe Penetrating / Ruptured Globe

Penetrating / Ruptured Globe : Management Penetrating / Ruptured Globe : Management

Stop examinationStop examination

Shield the eye (do not patch)Shield the eye (do not patch)

Give tetanus prophylaxisGive tetanus prophylaxis

NPO and systemic antibioticsNPO and systemic antibiotics

Do not apply eye ointment or eye dropDo not apply eye ointment or eye drop

Film orbit if IOFB can’t be R/OFilm orbit if IOFB can’t be R/O

Refer immediately to ophthalmologistRefer immediately to ophthalmologist

Intraocular or Intraorbital Foreign BodiesIntraocular or Intraorbital Foreign Bodies

Ocular TraumaOcular Trauma

Traumatic cataract

Traumatic mydriasis Traumatic lens subluxation

Traumatic lens subluxation

True ocular emergency

Both acid and alkali burns can be blinding

- Acid burns tend to coagulate proteins, limiting

the depth of penetration.

- Alkali burns can rapidly penetrate the cornea,

causing damage to intraocular structures.

Chemical Ocular InjuryChemical Ocular Injury

Immediate copious irrigation with a minimum of

1-2 L of saline or until pH is normalized ( 7.3-7.7 )

- Instill a topical anesthetic

- Use eyelid retractor

- Double eversion of the eyelids

Chemical Ocular Injury : ManagementChemical Ocular Injury : Management

Irrigation in case of chemical injuryIrrigation in case of chemical injury

Immediate copious irrigation with a minimum of

1-2 L of saline or until pH is normalized ( 7.3-7.7 )

- Instill a topical anesthetic

- Use eyelid retractor

- Double eversion of the eyelids

Chemical Ocular Injury : ManagementChemical Ocular Injury : Management

Ophthalmologists Referral

No corneal involvement

- ATB + steroid eye drop

Chemical Ocular Injury : Classification Chemical Ocular Injury : Classification

Grade I Grade II

Grade III Grade IV

Chemical Ocular Injury : Management Chemical Ocular Injury : Management

Preservative-free artificial tears

Topical non-preserved steroid

Topical cycloplegic

Topical antibiotics

Oral analgesics

Pressure patch or bandage CL

Antiglaucoma +

Bilateral Alkali Injuries

Chemical Ocular Injury Chemical Ocular Injury

Chemical Ocular Injury : Management Chemical Ocular Injury : Management

Corneal Transplantation

Keratoprosthesis

Accidental into the eye can cause the lids to

adhere and adhesive clumps to form on the cornea

Not permanently harmful to the eye

Cyanoacrylates are used occasionally directly on the

cornea to seal corneal perforations.

Cyanoacrylate GlueCyanoacrylate Glue

Moisten the glue with eye ointment, and remove

as much as can be removed easily without causing

damage to underlying tissue

The glue will loosen and become easier to remove

in a few days.

Cyanoacrylate GlueCyanoacrylate Glue

Non-traumatic Ocular EmergenciesNon-traumatic Ocular Emergencies

The woman suddenly experienced nausea, vomiting, and extreme The woman suddenly experienced nausea, vomiting, and extreme pain in the left eye while in a movie theater. Her vision has pain in the left eye while in a movie theater. Her vision has worsened since that time and the eye has become very red. worsened since that time and the eye has become very red.

A 55-year-old woman with a red eye, blurred A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomitingvision with halos, nausea, and vomiting

VA - HMVA - HM

Conjunctival injectionConjunctival injection

Hazy corneaHazy cornea

Shallow anterior chamberShallow anterior chamber

Fixed mid-dilated pupil Fixed mid-dilated pupil

A 55-year-old woman with a red eye, blurred A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomitingvision with halos, nausea, and vomiting

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

IOP 56 mmHgIOP 56 mmHg

Anterior Chamber DepthAnterior Chamber Depth

Reduce the intraocular pressureReduce the intraocular pressure

O.5% Timolol 1 drop O.5% Timolol 1 drop

2-4 % Pilocarpine 1 drop every 15 minutes2-4 % Pilocarpine 1 drop every 15 minutes

20% Mannitol 250-500 ml IV drip20% Mannitol 250-500 ml IV drip

Acetazolamide 500 mg oral Acetazolamide 500 mg oral

100% Glycerin 1 cc/kg 100% Glycerin 1 cc/kg

Consult ophthalmologistConsult ophthalmologist

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

A 60-year-old woman with acute, painless loss A 60-year-old woman with acute, painless loss of vision in the right eyeof vision in the right eye

Visual acuity CF – LPVisual acuity CF – LP in 90% of casesin 90% of cases

Opaque white retina and attenuated vesselsOpaque white retina and attenuated vessels

Central Retinal Artery OcclusionCentral Retinal Artery Occlusion

Treatment must be initiated immediately.Treatment must be initiated immediately.

Ocular massageOcular massage

Inhaled carbogen ( 95% O2 and 5% CO2 )Inhaled carbogen ( 95% O2 and 5% CO2 )

Reduced intraocular pressureReduced intraocular pressure

Central Retinal Artery OcclusionCentral Retinal Artery Occlusion

Consult ophthalmologist immediately Consult ophthalmologist immediately

Anterior chamber paracentesisAnterior chamber paracentesis

Direct infusion of t-PA or urokinase in the Direct infusion of t-PA or urokinase in the

ophthalmic artery ophthalmic artery

A 40-year-old man with left eyelid edema and painA 40-year-old man with left eyelid edema and pain ( worse on eye movement )( worse on eye movement )

A 40-year-old man with left eyelid edema and painA 40-year-old man with left eyelid edema and pain ( worse on eye movement )( worse on eye movement )

Periorbital erythema and edema

Proptosis

Restricted extraocular motility

Decreased visual acuity

Chemosis

Fever

Orbital CellulitisOrbital Cellulitis

Broad spectrum intravenous antibioticsBroad spectrum intravenous antibiotics

CT scan orbitCT scan orbit

Ophthalmology & ENT consultation Ophthalmology & ENT consultation

Orbital CellulitisOrbital Cellulitis

Subperiosteal abscess

Preseptal CellulitisPreseptal Cellulitis

EndophthalmitisEndophthalmitis

Urgent Neuro-ophthalmologyUrgent Neuro-ophthalmology

A 36-year-old-woman with subacute visual loss in right eye and pain on eye movement

VA 20/200, 20/25 RAPD +ve OD

VF central scotoma OD

Retrobulbar optic neuritis

A 55-year-old man with HT and acute visual loss in RE

VA 20/100, 20/20 RAPD +ve RE

Nonarteritic anterior ischemic optic neuropathy

ESR 10 mm/hr

A 73-year-old woman with acute visual loss of right eye, headache, anorexia and weight loss

VA 10/200, 20/25 RAPD + ve RE

ESR 94 mm/hr, high level of C - reactive protein

Arteritic anterior ischemic optic neuropathy

Pathology : Giant Cell ( Temporal ) Arteritis

A 35-year-old man with left painful third nerve palsy

VA 20/25, 20/30

Dilated, nonreactive pupil LE

A 35-year-old man with a suspicious of aneurysmal third nerve palsy

Conventional CT scan or MRI are not the procedure of choice

High false negative rate 12 – 40 %

Magnetic resonance angiography (MRA)

Computed tomography angiography (CTA)

Overall sensitivity up to 97 %

A 35-year-old man with a suspicious of aneurysmal third nerve palsy

A 40-year-old woman with sudden onset of left third nerve palsy, visual loss and severe headache

What is the diagnosis?

VA 20/30, LP +ve RAPD LE

Pituitary Apoplexy

Characterized by sudden visual loss, headache, and ophthalmoplegia secondary to rapid expansion of pituitary macroadenoma into the suprasellar space and/or cavernous sinus

Commonly results from hemorrhage into a pre-existing pituitary mass

A 17-year-old man with right blured vision after minor blunt trauma.

VA 20/32, 20/20 + ve RAPD RE

Normal fundi

RELE

A 16-year-old man with head injury and left blured vision after falls from height

VA 20/30, LP + ve RAPD LE

Normal fundi

Traumatic Optic Neuropathy :

Classification and Mechanisms

Direct injury

- Penetrating injury from knife, projectile

- Injury from fractured bone

- Avulsion, transection

Indirect injury

- Contusion with transmission of force through bone

- Compression secondary to orbital hemorrhage or

intrasheath hemorrhage

Clinical Features of Traumatic Optic Neuropathy

Most commonly unilateral

May be overlooked in setting of significant

globe or maxillofacial trauma

Reduced visual acuity ( NLP to 20/20 )

Visual field defect : No pathognomonic defect

Normal optic disc with development of optic atrophy

Medical Management Options

Steroids : Controversial

- Thought to limit free-radical amplification

of the injury response

- Dosages ( low, high, mega)

- May be harmful

Observation : 57% of untreated patients shown to have 3 lines or more acuity improvement

Surgical Management Options

Lateral canthotomy and cantholysis for orbital hemorrhage

Surgical decompression of the optic nerve within its canal

There is no defined standard protocol of

treatment for indirect optic nerve injury .