1. Ophthalmic Emergencies
How to avoid missing a serious and treatable condition
Hong Woon SJUH, Leeds

2. Ophthalmic Emergencies
Ophthalmic emergencies with obvious clinical signs
Ophthalmic emergencies without obvious clinical signs

3. Alkali burns
Fertilizers and cleaning products/ drain and oven cleaners/ cement
Must treat immediately with irrigation before referring on.
Irrigate with copious amounts of water/ buffer solution until pH normal
Untreated can become blind due to stromal damage and ischaemia

4. Beware infection in CL wearer of if recent operation
Painful red eye: - may indicate infective keratitis/ endophthalmitis
Urgent treatment required

5. Dendritic ulcers Self limiting
Problem occurs if treated with topical steroids

6. Ophthalmic emergencies without obvious clinical signs
Choices:
Make diagnosis from examination
Become competent at slit lamp and fundus examination
Make diagnosis from symptoms
Learn to take a good history

7. What to ask for when taking a history of visual loss?
Character of visual loss may help identify location of disease:
Extent of visual loss: sharpness / darkness / field loss
Blurred vision: Out of focus / Distorted vision
Floater
Glare / Halos
Timing: onset / progressive / transient
Associated factors: pain / headache

8. Extent of visual loss
Very important clue about severity of problem
Ask about vision of each eye
Vision of less than CF is indicative of serious disease
But remember serious disease can also be present if vision is good

9. Quantify extent of visual loss with vision test
Sit patient at correct distance from chart
Test each eye individually
Ask patients to use distance glasses
Use pinhole if no glasses
If unable to see any letters
? CF, ?HM, ?PL
Compare with previous vision

10. Blurred vision Out of focus / not sharp No distortion
Refractive problem
Cornea
Lens
Shape of eye
Macular problem

11. Distortion of vision (Metamorphopsia)
Things look wavy, jumbled up. Lines not straight. Kink in lines
Condition affecting retina
Wet macular degeneration
Macular hole
Macular pucker
Retinal detachment

12. Field defect Curtain, bit missing, bump into things
Always a sign of serious problem
If homonymous: -same visual field both eyes
Defect of visual pathways
Not hononymous
Retinal
Optic nerve

13. Shadow in the eye Retinal detachment Glaucoma Vitreous haemorrhage
Vascular lesion
Optic nerve disorder
Visual pathway problem

14. Floater
Due to opacity in vitreous
Fly/spider, blob, haze
Movement

15. Floaters PVD May notice Weiss’ ring Syneresis Vitreous haemorrhage
Rain drops
Black streaks
Posterior uveitis

16. Flashes PVD Moores lightening streak
Peripheral scintillation with eye movement
Migraine
Scintillating scotoma
Fortification spectrum
Mass lesion
Retinal ischaemia

17. Glare Difficulty seeing in bright light Corneal or lens problem
Low sun
Driving at night
Fluorescent light in supermarkets
Corneal or lens problem
Often due to cataract
Vision may be good otherwise

18. “Halos” in acute glaucoma
Not strictly a halo – diffraction of light by ice crystals
Coloured rings around lights due to refraction by water droplets
Not to be confused with glare due to scatter by corneal or lens opacities

19. Reduced colour sensitivity
Things look darker / less colour
Optic nerve disease
Optic neuritis
Compressive optic nerve disease
Condition affecting retina
Wet macular degeneration
Central serous retinopathy

20. Timing of visual loss Recent or chronic Static or progressive
Transient or persistent
Very important in determining urgency of situation

21. Conditions causing sudden visual loss Vascular occlusion
Central retinal artery occlusion
Central retinal vein occclusion
Anterior ischaemic optic neuropathy
Vitreous haemorrhage
Acute glaucoma
Conditions causing rapid progressive visual loss
Retinal detachment
Wet macular degeneration

22. Causes of transient visual loss
Amaurosis fugax
Subacute angle closure glaucoma
Visual obscuration due to papilloedema
Giant cell arteritis
Floaters
Ocular surface problem

23. Symptoms suggestive of urgent condition
Marked visual loss
Field loss
Floaters/Photopsia
Distortion of vision
Transient marked loss of vision
Recent change
Rapidly progressive change

24. Ophthalmic emergencies without obvious clinical signs
Subacute angle closure glaucoma
CRAO
AION
Wet macular degeneration
PVD with retinal tear/detachment
Retinal detachment
Trauma
CRVO
Neurological conditions presenting with eye signs/symptoms

25. Subacute angle closure glaucoma
Acute angle closure glaucoma – ophthalmic emergency with obvious clinical signs
Red eye
Painful eye
Severe visual loss in affected eye
Often premonitory episodes of subacute angle closure glaucoma

26. Subacute angle closure glaucoma
Angle closure develops in evenings when pupil dilates
Pressure increases to give pain and corneal oedema
Patient sees blurred vision and haloes around lights
Patient goes to bed
Sleep induced miosis aborts attack of glaucoma
Normal eye next day
Should be referred urgently before established AACG develops

27. Treatment of to prevent angle closure glaucoma
YAG PI
Laser treatment
PI prevents build up of aqueous behind pupil

28. Central retinal artery occlusion
Sudden severe visual loss
Visual loss may not be total due to cilioretinal artery
Usually embolic, rarely due to GCA
Attempt to reperfuse artery if within 24 hours of onset
Should be seen urgently to exclude GCA and identify cause
No recovery of vision
Often premonitory symptoms

29. Amaurosis fugax
Transient visual loss due to passage of emboli through central retinal artery
Recovery to normal vision unless permanent central retinal artery occlusion develops
Often no emboli visible on clinical examination
Total or altitudinal visual loss in one eye for a few minutes
Visual recovery often described like a curtain lifting
Aspirin very effective in preventing CRAO

30. Cause of CRAO is usually carotid disease
Risk factors:
Hypertension, Smoking, Diabetes, High Cholesterol
Risk of further emboli to eye or brain
Reduce risk factors
Antiplatelet agents
Carotid endarectomy if greater than 70% stenosis

31. Anterior ischaemic optic neuropathy
Infarction of optic nerve head - pale swollen disc with visual loss.
Sudden severe visual loss if entire disc affected, altitudinal defect if only one short posterior ciliary artery occluded

32. Anterior ischaemic optic neuropathy
No treatment for affected eye
75% due to atherosclerosis in middle aged smokers
25% due to Giant cell arteritis - headache, tenderness of temporal arteries, malaise, raised ESR .
AION due to GCA is emergency - high risk of developing AION in fellow eye

33. Wet macular degeneration 1. Serous elevation of retina or PED 2
Wet macular degeneration 1. Serous elevation of retina or PED 2. Blurred vision and distorted vision 3. Usually progressive over weeks 4. Difficult to see with ophthalmoscope 5. Initial vision may be very good

34. Wet ARMD Highly likely to progress to severe visual loss if untreated
Recovery of vision best if treated before chronic changes have developed
Treatment not recommended for late cases

35. Treatment of CNM with intravitreal injection of antiVEGF
VEGF (vascular endothelial growth factor) stimuates growth of choroidal neovascular membrane
antiVEGF binds to VEGF and prevents it acting on CNM
Visual loss can be reversed if caught early

36. Diagnosis of posterior vitreous detachment
Flashes and floaters
Weiss’ ring
Age, myopia, cataract operation
Examination
Weiss’s ring
Posterior hyaloid membrane

37. Symptomatic Posterior Vitreous Detachment
Risk of developing retinal tear (8-22%)
Risk of developing RD: 3 – 7% in symptomatic PVD
If RD develops, it usually occurs within 6 weeks

38. Symptomatic Posterior Vitreous Detachment
Indications for urgent referral
Recent history (? Within 6weeks)
Symptoms suggestive of vitreous haemorrhage
Symptom of retinal detachment
Reason for urgent referral
To pick up retinal tear before retinal detachment
Early treatment of retinal detachment

39. Penetrating ocular injury
Suspect if history of high velocity fragment – ie metal on metal fragment
May be minimal external eye signs.

40. Symptoms suggestive of urgent condition
Marked visual loss
Field loss
Floaters/Photopsia
Distortion of vision
Transient marked loss of vision
Recent change
Rapidly progressive change