1. Dr Mahmood Fauzi Assist. Prof Ophthalmogy
Ocular Emergencies
Dr Mahmood Fauzi
Assist. Prof Ophthalmogy

2. Eye Anatomy
Illinois EMSC

3. Ocular Emergencies Lid Lacerations Foreign Bodies
Corneal Lacerations/Abrasions
Penetrating Injuries and Contusions of the Eyeball
Globe Rupture
Burns of the Eye
Chemical injuries
Orbital Fractures
Acute congestive glaucoma

4. Facts to elicit from the history
General
Are both eyes affected or only one?
Time of onset
Recurrence
Events preceding the current state
Recent history of ocular disease or surgery
Other diseases, specifically cardiac, vascular, or autoimmune
Family history for ocular problems
Current medications or recent changes to medications
Changes in vision (lost, blurred, or decreased vision; diplopia, sudden or gradual)
Visual acuity before the current event
Other symptoms (pain, nausea, vomiting)

5. Emergency Eye Examination
Visual acuity
External examination
Pupils
Extraocular muscles
Injection
Discharge
Preauricular lymphadenopathy
(usually viral)
Follicles
(usually viral; chronic – r/o chlamydial)
Papillae
(usually allergy)
Follicles
Papillae

6. Emergency Eye Examination,
Cornea-fluorescein test
Evert lid
IOP
Confrontational fields
Ophthalmoscopy
Lab & radiology testing
Treat/refer/consult
Pearls
Infection control
Chemical injuries, irrigation STAT, Morgan lens
Compare both eyes
Iritis

7. Corneal Abrasion

8. Corneal Abrasions History of scratching the eye Symptoms:
Foreign body sensation
Pain
Tearing
Photophobia

10. Corneal Abrasions Treatment: Topical antibiotic
Pressure patch over the eye
Refer to ophthalmologist

11. Corneal Ulcer
Corneal ulcer occur secondary to lid and conjunctival inflammation but is often due to trauma or contact lens wear
Bacterial, viral, fungal or parasitic

12. Corneal Ulcer
Ocular pain, redness and discharge with decrease vision and white lesion on the cornea

13. Corneal Ulcer
Prompt diagnosis of the etiology by doing corneal scraping
Treatment with appropriate antimicrobial therapy are essential to minimize visual loss

14. Contact lens wearer
Any redness occurring for patients who wear contact lens should be managed with extreme caution
Remove lens
Rule out corneal infection
Antibiotics for gram negative organisms
Do not patch
Follow up with ophthalmologist in 24 hours

15. Chemical Injuries A vision-threatening emergency
The offending chemical may be in the form of a solid, liquid, powder, mist, or vapor.
Can occur in the home, most commonly from detergents, disinfectants, solvents, cosmetics, drain cleaners…..

16. Chemical Injuries
Can range in severity from mild irritation to complete destruction of the ocular surface
Management
Instill topical anesthetic
Check for and remove foreign bodies

17. Chemical Injuries
Immediate irrigation essential, preferably with saline or Ringer’s lactate solution, for at least 30 minutes

18. Chemicals Injuries
Irrigation should be continued until neutral pH is reached (i.e.,7.0)
Instill topical antibiotic
Frequent lubrications
Oral pain medication
Refer promptly to
ophthalmologist

19. Burns Chemical Burns Heat Burns Light Burns Call EMS
Irrigate continuously, gently
Heat Burns
Apply a loose, moist dressing
Light Burns
Symptoms delayed - bilateral
Cover both eyes with dark patches
Illinois EMSC

20. Alkali Burn of the Cornea
Illinois EMSC

21. Corneal and Conjunctival Foreign Bodies
History of trauma
Foreign body sensation-Tearing

22. Corneal and Conjunctival Foreign Bodies
Management
Instill topical anesthetic
Removal of the foreign body
Topical antibiotic
Treat corneal abrasion

23. Fluorescein Stain

24. Linear epithelial defects suggestive of foreign body under the eye lid
KEY ED MANAGEMENT: If patient history worrisome for foreign body, but nothing is visualized on initial exam, EVERT the eyelids. Many foreign bodies become lodged in upper lid and are not visible on initial exam.

25. Blunt trauma Superficial FB – flourescein stain
fractures, hemorrhage, or damage to the globe or adnexa
Fx sharp edges that can cause entrapment or damage to the muscle or globe
Retrobulbar hemorrhage - analogous to compartment syndrome
elevated intraocular and extraocular pressures, causing permanent damage
Hyphema
warrants suspicion for penetrating trauma, orbital fracture, acute glaucoma, or retinal detachment

26. control swelling and pressure
CT for fracture, retrobulbar hemorrhage, laceration, or intraocular foreign body
control swelling and pressure
Cold compresses
Nasal decongestants
Lateral canthotomy
tetanus prophylaxis

27. Orbital Floor or Blow-Out Fracture
Trauma
Orbital floor – most common
Symptoms
Diplopia
Restricted eye movement
Hyposthesia
Air accumulation
Sunken eye
View globe inferior
Crepitus – nose blowing

28. Orbital Floor or Blow-Out Fracture
Pearls
Broad-spectrum po antibiotic
Cold compress – ice pack
Nasal decongestants
Nose blowing
Retinal detachment – coup, counter-coup
CAT scan of orbit
Refer always, same day
Opthalmology, ENT

29. Preseptal Cellulitis

30. Preseptal Cellulitis Lid swelling and erythema
Visual acuity ,motility, pupils, and globe are normal

31. Preseptal Cellulitis Etiology Puncture wound Laceration
Retained foreign body from trauma
Vascular extension, or extension from sinuses or another infectious site ( e.g.,dacryocystitis, chalazion)
Organisms
Staph aureus – Streptococci- H.influenzae

32. Preseptal Cellulitis Management: Warm compresses Systemic antibiotics
CT sinuses and orbit if not better or +ve history of trauma

33. Orbital Cellulitis Pain Decreased vision
Impaired ocular motility/double vision
Afferent pupillary defect
Conjunctival chemosis and injection
Proptosis
Optic nerve swelling

35. Orbital Cellulitis Management: Admission Intravenous antibiotics
Nasopharynx and blood cultures
Surgery maybe necessary

36. Orbital Cellulitis

37. Penetrating/lacerating trauma
damage or destroy anatomic structures
compromise protective outer layers, increasing the risk of infection
Sympathetic ophthalmia
<2%

38. Penetrating Injury r/o rupture eye protected – fox shield CT
If rupture no further exam - EUA
eye protected – fox shield CT
systemic antibiotics initiated- NOT topical
NPO, time of last meal
tetanus prophylaxis

41. Lid repair Avoid retraction of lid margin Check canilicular system
Gray line to gray line
Check canilicular system
Remove FB
Tetanus prophylaxis

42. “Eyelids don’t have fat”
Orbital fat usually protrudes through septal lacerations
Fat in the lid laceration confirms the diagnosis
High incidence of globe penetration and intraocular foreign bodies
High risk for orbital cellulitis

44. Ruptured globe
Penetrating trauma leads to corneal or scleral disruption and extravasation of intraocular contents.
Can lead to:
Irreversible visual loss
Endophthalmitis -inflammation of the intraocular cavities

45. Ruptured Globe Signs and symptoms:
pain, decreased vision
hyphema
loss of anterior chamber depth
“tear-drop” pupil which points toward laceration
severe subconjunctival hemorrhage completely encircling the cornea.
Diagnosis: positive Seidel’s test, clinical exam.

46. Ruptured Globe Management
Stop the examination
Cover with metal eye shield or styrofoam cup. DO NOT PATCH.
Consult ophthalmology immediately
Do not perform tonometry.
CT head and orbit to evaluate for concomitant facial/orbital injury.
NPO, tetanus
Antibiotics: Cefazolin + ciprofloxacin provides good coverage.
Antiemetics and analgesics decrease risk of Valsalva or movement which could increase IOP.

47. Acute Angle Closure Glaucoma (AACG) - Diagnosis
History: Acute onset, higher risk in far-sighted
Symptoms:
Pain
Halos (around lights)
Visual loss (usually peripheral)
Nausea/vomiting
Signs:
Conjunctival injection
Corneal edema
Mid-dilated, fixed pupil
 IOP (normal: 10 – 20 mmHg)
An attack of acute angle-closure glaucoma in predisposed persons can occur as a result of dim lighting or use of certain medications (e.g., dilating drops, anticholinergics, antidepressants). Medications such as sulfa derivatives and topiramate (Topamax) can cause swelling of the ciliary body and secondary angle closure.

48. Glaucoma - Pathophysiology
Aqueous humor produced by ciliary body, enters ant. chamber, drains via trabecular meshwork at angle to enter canal of Schlemm
In AACG, iris obstructs trabecular meshwork by closing off angle
Optic nerve damage 2° IOP

49. Acute Angle Closure Glaucoma
Medical Tx
Reduce production of aqueous humor
Topical -blocker (timolol 0.5% gtt)
Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po)
Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min)
Or increase outflow
Topical -agonist (phenylephrine 1 gtt)
Miotics (pilocarpine 1-2%)
Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then Q1H
Definitive Tx
Ophtho referral: Laser peripheral iridectomy

50. Eye Injury Prevention Education Require use of protective eyewear
Investigate causes of eye injuries and remove hazards
Collaborate with school staff to reduce incidence of injury
Illinois EMSC

51. “Your job is to make discussions.”
“If two people agree on everything, then only one of them is thinking.”
- Senator Sam Rayburn
“Your job is to make discussions.”
Pierre Rouzier, M.D.

52. A “Red Eye”
Patient presents whose right eye is red, painful and very sensitive to light.
When you shine the penlight in her left eye, it causes her pain in the right (affected) eye.
What diagnosis does it suggest?

53. Another red eye
A three-year old child presents with erythema and swelling around the left eye.
The Pediatric resident says, “It’s periorbital cellulitis; start the kid on antibiotics and send him home.”
Are you comfortable with that?

54. Poked in the eye!
A young boy presents to the ER after having been poked in the eye by another student.
He is being seen by a resident who is just about to measure the child’s intra-ocular pressure when you yell “STOP!!!!!!”
Why are you so uptight?
Now what should you do?

55. Drain cleaner in the eye
A patient comes to the ER having gotten some drain cleaner in her eye and it's causing her a lot of pain.
The triage nurse tells her the wait to be seen is 1 hour and the patient becomes irate and starts to leave.
You happen to overhear this conversation
What should you do? Why?
Treatment?
How long?

56. Baseball versus eye
A young male presents to the ER after having been hit in the eye with a baseball. He says, "I keep seeing double when I look up".
Diagnosis?
Pathophysiology?
Treatment?

57. FB sensation
A young male presents to the ER with foreign body sensation to this left eye.
He was pounding a nail and felt something get into his eye.
You examine patient and find that other than some photophobia, his exam is normal.
You are about to discharge him when the attending says, hold on just a minute. What could you have possibly missed?
How do you make the diagnosis?

58. Positive Seidel’s
You carefully examine the patient and place fluorescein in his eye. You see the fluorescein streaming.
What is this called?
What does it signify?
Where could be the likely truama?

59. Red Eye Danger Signs Decreased visual acuity Pain Ciliary flush
Pupillary asymmetry
Irregular corneal light reflex
Corneal infiltrate
Photophobia
Trauma

60. Emergency Eye Examination
Visual acuity
External examination
Pupils
Extraocular muscles
Injection
Discharge
Preauricular lymphadenopathy
(usually viral)
Follicles
(usually viral; chronic – r/o chlamydial)
Papillae
(usually allergy)
Follicles
Papillae

61. Ocular Injection Conjunctival injection
Conjunctivitis
Ciliary (circumcorneal) injection
Keratitis
including corneal abrasions, foreign bodies
Iritis
Glaucoma

62. Ocular Injection Segmental injection Episcleritis Injected pinguecula
Embedded foreign body
Marginal keratitis
Phlyctenular limbal keratoconjunctivitis

63. Non- Vision Threatening Red Eye
Conjunctivitis
Stye (hordeolum)
Chalazion
Blepharitis
Conjuctival foreign bodies

64. Subconjunctival Hemorrhage
Pearls
No trauma
normal vision, no pain, self-limited, benign
Trauma
r/o intraocular injury
Worse day 2? BP
Treatment?
ASA?
When to refer
Concommitant trauma

65. Stye (hordeolum) Infection Treatment WC P.o pain medication
Usually staph aureus
Treatment WC
P.o pain medication
Topical antibiotics
Systemic antibiotics
lid cellulitis or pain?

66. Cyst (chalazion) Inflammation Treatment Pearls WC Near lid margin R/o
steroid injection
Pearls
R/o
rosacea
malignancy w/recurrence
Systemic doxycycline

67. Cyst (chalazion) When to refer Not resolving in 2 – 3 weeks Cosmetic
Vision
Lid margin

68. Vision-Threatening Red Eye & Emergencies
Corneal abrasions
Conjunctival & corneal foreign bodies
Keratitis
Iritis
Hyphema
Blow-out fracture
Retinal detachment
Papilledema

69. 4th Generation Fluoroquinolones
Options:
Zymar, Allergan (gatifloxacin)
Vigamox, Alcon (moxifloxacin)
Benefits:
lower incidence of resistance
may shorten infection
more effective for gram +
potency, concentration
active – pseudomonas aerunginosa
permeability, solubility
comfort

70. Thank you