Eye Emergencies

Dr Dane Horsfall

Emergency Physician

Cabrini Emergency Department

Overview

Eye Anatomy/Terminology History/Examination Red Eye Acute visual loss Eye Trauma

Anatomy

Anatomy

Terminology Keratitis = inflammation of

cornea Blepharitis = inflammation of the

eyelid Iritis = inflammation of Iris Uveitis = inflam of uvea, (middle

layer-iris, ciliary body and choroid) Anterior uveitis (most

common) – inflam. iris and ciliary body aka “Iritis”

Intermediate uveitis – inflam. ciliary body

Posterior uveitis – inflam. choroid

Diffuse uveitis - all

History/Examination Glasses? Contact Lenses? Previous eye

conditions/trauma/surgery/meds Visual Acuity

Snellen chart x/y X is distance from chart (ie 6

metres) Y is smallest font size read Eg Normal 6/6, just top line

6/60 Vision less than 6/60 count no.

of fingers/hand movements/light perception

Pin hole corrects refractory error to 6/9 or better

Examination Visual Fields Evert eyelids-local

anaesthetic (Amethocaine) aids thorough eye exam

Eye movements “H” CN III, IV, VI palsies, fatigability (myasthenia)

Examination Ophthalmoscopy: dark, dioptric to zero, pt focus on

corner of room Pupils

Reflex Symmetry

Cornea Lens Humour Retina-Fundoscopy-dilate pupil-Tropicamide Can use cobalt blue light with fluorescein

Examination Slit Lamp-where is it?

Lateral canthus at black line on frame Pt to look at examiners R ear when examining R eye Joystick to focus Cobalt blue light for fluorescein-NOT green light filter.

But Fluorescein dye appears green under blue light

Painful Red Eye

Case: 65yo F, 1/52 increasing

R unilateral eye pain assoc n/v, Dx as migraine

o/e visual acuity reduced hazy cornea fixed mid-dilated pupil hard eyeball

Acute Angle Closure Glaucoma Females in 60-70s, esp. Asians/Eskimos, +ve FHx defined as

> 2 of ocular pain, nausea/vomiting, intermittent blurred vision with halos

and at least 3 of: conjunctiva injection corneal epithelial oedema = hazy mid-dilated non-reactive pupil IOP >21 mmHg can be >60 mmHg shallower chamber in the presence of occlusion.

Acute Angle Closure Glaucoma Aqueous humor

produced by ciliary body (posterior chamber)

passes thu pupil into ant chamber drained via trabecular meshwork and canal of Schlemm in the angle.

Contact between the lens and the iris blocks flow, pressure in posterior chamber - iris bows forward closing angle – reduce drainage

Precipitated by dilated pupil- darkness, stress, medications (anticholinergic, sympathomimetic)

Chronic open angle- no pain no attacks-slow progressive vision loss

Acute Angle Closure Glaucoma Intra-ocular pressure

measurement: Normal 10-20mmHg Goldman applanation

tonometer: attached to the slit lamp

Storz/Schiotz Tonometer Tono-Pen handheld electronic

contact tonometer ($3000)

Acute Angle Closure Glaucoma

Mx Ophthal. referral Acetazolamide 500mg IV Topical beta-blocker Topical steroid Analgesics/Anti-emetics/Supine Once pressure-induced ischemic paralysis of the iris

resolves around 1 hour post initial Rx then: Pilocarpine: a miotic (constricts pupil) – opens angle,

should be administered every 5 mins for 30 mins Laser peripheral iridotomy performed 24-48 hours after

IOP is controlled is definitive treatment

Famous Eyes

Who’s eyes are they?

Painful Red Eye

Case: 45yo F with unilateral

red, painful eye PHx Crohn’s Disease o/e blurred vision,

perilimbal injection, Slit lamp

“floaters/debris in anterior chamber”

Acute Anterior Uveitis (Iritis) Unilateral, painful red eye, blurred vision,

photophobia, and tearing Peri-limbal injection, worse closer to

limbus: (conjunctivitis= worse further from limbus)

Visual acuity may be decreased Examine anterior chamber with Slit lamp

Increase in protein content of aqueous causes an effect known as “flare”, looks “smokey”

White or red blood cells may be observed in the anterior chamber

Severe cases - inflam. cells accumulate as sediment in ant. chamber = Hypopyon

Iritis

Causes 50% idiopathic Assoc

CTD (ankylosing spondylitis, inflammatory bowel disease, Reiter syndrome, psoriatic arthritis, sarcoidosis)

Infections: Herpes, syphilis, TB, toxoplasmosis, histoplasmosis, CMV, Candida

Trauma Mx Referral: steroids and cycloplegics,

antimicrobials.

Painful Red Eye

Herpes simples – dendritic ulcers Rx topical Acyclovir

Bacterial Ulcer or Acanthamoebal ulcer: amoeba assoc contact lens Mx urgent Ophthal ref. ?admit/antimicrobials

Painful Red Eye - Eyelid Chalazion - eyelid cyst inflam. of

blocked meibomian gland -usually painless and larger. Rx warm compresses/antis/usually resolve can inject steroids/surgically remove

Stye – infection (staph) of the sebaceous glands at base of the eyelashes. Rx warm compress, pull out eyelash, antis

Blepharitis – inflam. eyelid can be infective. Rx warm wet compress/antis

Herpes Zoster – vesicular rash, can cause infection of all parts of eye. Nasociliary branch involvement predicts serious complications: ocular inflam. and corneal denervation. Mx Opthal ref, Acyclovir

Painful Red Eye

Conjunctivitis Viral - recent URTI,

clear, watery discharge Allergic –pruritus,

clear, watery discharge Bacterial – pus, swab,

staph/strep/ gonococcal/chlamydia, Rx Chlorsig

Red Eye Scleritis:

Inflam sclera- localized, nodular, or diffuse

Vision may be impaired Sclera thick, discoloured Severe pain Assoc with CTD (esp RA) and

Vasculitis Mx Analgesia, Ophthal ref

steroids/immunosuppressant Pterygium :

raised yellow, fleshy lesion at limbus, may be inflamed

Asymptomatic or redness, swelling, itching, irritation, blurred vision

r/f UV, FHx, Male Mx lubricant, sunglasses, refer -

surgery

Famous Eyes

Who’s eyes are they?

Case 60yo M Sudden, painless

loss of vision L eye, previous partial/intermittent loss of vision over a few days

PHx IHD, HT, DM L eye light perception

only, relative afferent pupillary defect

Fundus: pale, arteries/veins narrowed

Central Retinal Artery Occlusion Embolism

Most commonly cholesterol, cardiac (assoc HT,DM) can be calcific, bacterial, Giant cell arteritis

Amaurosis Fugax : transient loss of vision lasting seconds to minutes, can precede

Mx Urgent ophthal referral Decrease intra-ocular pressure

Acetazolamide/Anterior chamber paracentesis

Move clot Pulsed ocular compression Anticoagulate Intra-arterial fibrinolysis

Central Retinal Vein Occlusion Sudden painless loss of vision R/F: age, HT, DM,

prothrombotic disorders Types: Non-ischaemic and

Ischaemic Signs: Decreased visual

acuity, Relative Afferent pupillary Defect, abnormal red reflex

Fundus haemorrhage (“Stormy sunset”)

Mx Ophthal referral Anticoag, aspirin Surgery incl. Laser

photocoagulation

Optic Neuritis

Vision loss (esp. colour) over hours-days, pain with eye movements, central scotoma

Usually unilateral, F 18-45yo may be 1st presentation of demyelinating disease-MS

Swollen optic disc May have other neurology Mx Ophthal referral, IV

IV steroids

Giant Cell Arteritis AKA Arteritic Ischaemic Optic

Neuropathy Females, 60’s Profound unilateral visual loss Check for

Jaw claudication Headache Scalp tenderness Polymyalgia Rheumatica in 50%

Fundus: disc oedema ESR >60mm/hr Rx Ophthal referral,

Prednisolone

Retinal Detachment Result of retinal hole with

seepage of fluid between retina and choroid

R/F age, trauma Signs

flashing lights, floaters Vision loss may be filmy,

cloudy, irregular, or curtainlike Visual field defects

Mx Ophthal ref., Repair Laser therapy Cryotherapy Intraocular gas (ie, pneumatic

retinopexy) tamponades retina Intraocular repair

Famous Eyes

Who’s eyes are they?

Eye Trauma

Corneal injuries

Corneal Abrasion Sensation of foreign body, light

sensitivity, tearing Local drops (Amethocaine 0.5%) Fluorescein with blue light Rx Chlorsig (drops/ointment)

Corneal Flash burns Arc welding/UV lamp Red, painful, tearing LA, Fluorescein Rx Chlorsig

Corneal foreign body

Dirt/glass/metal (rust ring) Velocity of impact Signs of penetration Removal

Local 25G needle, lateral

approach using slit lamp Dental burr for rust ring

(adherent rust ring may loosen with Chlorsig/patch for 24hrs as the cornea heals, may recall pt)

Chemical burns Acids: toilet/pool cleaner,

battery fluid Alkalis (more harmful): lime,

mortar/plaster, drain cleaner, oven cleaner, ammonia

Immediate Mx: LA copious irrigation with fluid-bag of N/Saline + Morgan Lens until pH 7.5, test aquity

Degree of vascular blanching (esp at limbus) proportional to severity of burn

Chlorsig, Ophthal. referral

Blunt Trauma - Haemorrhage Subconjunctival Hemorrhage

usually benign, if spont. Check BP/Coags

If cant see post border ?Orbital # Hyphaema: blood in anterior chamber

If >1/3 = damage to drainage angle, risk glaucoma

Mx shield/patch/semi-recumbent/rest +/- sedation/admission no NSAIDs, Ophthal. Ref.

Recurrent bleeding in 10% esp with early mobilization

Hemorrhage vitreous or retina, can be accompanied by a retinal detachment.

Iris damage can result in poor pupil reactivity = Traumatic mydriasis. Misleading Neuro signs

Lens can be damaged or dislocated and a cataract may develop

Blunt trauma - Orbital blowout fracture

Usually inferior wall since weakest Signs:

Diplopia/Ophthalmoplegia from muscle entrapment. Tethering of inferior rectus prohibits the upward movement of the globe.

Proptosis from swelling or retrobulbar hemorrhage and later Enophthalmos from loss of volume

Infraorbital nerve entrapment- numb cheek/upper teeth

Epistaxis 30% incidence of a ruptured globe in

conjunction with orbital fractures. (Wilkins RB, Havins WE. Current treatment of blow-out fractures. Ophthalmology. May 1982;89(5):464-6)

Blowout Fracture Mx

Repair: Indicated if significant diplopia or cosmetically unacceptable enophthalmos. Most surgeons will wait 10 to 14 days following the trauma to allow for resolution of the associated edema and hemorrhage

Medical : if no diplopia/enophthalmos o antis/no nose blowing/?

steroids

Ruptured Globe May be from blunt or

penetrating trauma Occurs at thinnest part:

Limbus (Visible with slit lamp) Insertions of the extra-ocular

muscles (reduced eye movements, loss red reflex from vitreous haemorrhage)

Around the optic nerve Signs:

Pupil : peaked, teardrop-shaped, or otherwise irregular

Seidel’s Sign Enophthalmos (recession of

the globe within the orbit) Exophthalmos from retrobulbar

hemorrhage

Ruptured Globe Ix: CT most sensitive Mx : Anti-emetics/analgesics/prophylactic

antibiotics/tetanus/fast Urgent Ophthal. referral always requires surgical

intervention. ? Suxamethonium in open globe injury

controversial, weigh up risk to airway Mx and theoretical risk of ocular extrusion and ask opthal.

Penetrating Eye Trauma Easily missed since may seal over and abnormal signs may

be subtle High risk with high velocity eg metal striking metal and glass Leave bodies insitu until surgery Signs:

Distorted pupil Cataract Prolapsed black uveal tissue on the ocular surface Vitreous hemorrhage. Seidel’s Sign Shallow/flat anterior chamber or bubbles in anterior chamber

Mx as for ruptured globe

Lid Lacerations

Require Ophthal. ref. if: Torn lid margins - must

be closed accurately Lacrimal ducts damage Any suspicion of a

foreign body or penetrating eyelid injury

Mx refer/Tetanus/iv antis/antiemetics/shield eye

Famous Eyes

Who’s eye’s are they?

Golden Rules

Always check visual acuity Always attempt to open eye early and

examine pupil/acuity etc in trauma Beware Dx unilateral conjunctivitis until more

serious disease is excluded Don’t D/C pt with LA drops - impedes

healing, further injury may occur to anaesthetized eye.

Don’t start Steroid drops without ophthalmology r/v

References Globe Rupture, J Robson, Feb 16 2007, www.emedicine.com Handbook of ocular disease, 2000 - 2001 Jobson Publishing,

www.revoptom.com/handbook/hbhome.htm P T Khaw et al, Clinical review “ABC of Eyes- Injury to the eye” BMJ  2004;328:36-

38 (3 January) Cameron et al, Textbook of Adult Emergency Medicine, Second Ed, Churchill

Livingston, 2004 Eye Emergency Manual, NSW Ophthalmology Service, 2007 Retinal Detachment, G Larkin , Apr 7, 2008 www.emedicine.com Acanthamoeba, N Crum-Cianflone, Jun 30 2008, www.emedicine.com Facial Trauma, Orbital Floor Fractures (Blowout), A Cohen, Dec 18 2006,

www.emedicine.com Glaucoma, Acute Angle-Closure, A Darkeh, Oct 3 2007, www.emedicine.com Scleritis, T Gaeta, Apr 14 2008 www.emedicine.com Wilkins RB, Havins WE. Current treatment of blow-out

fractures. Ophthalmology. May 1982;89(5):464-6