Ocular Emergencies Ocular Emergencies Abdullah Alfawaz, MD,FRCSAbdullah Alfawaz, MD,FRCS
Ass. Prof. Cornea/Uveitis service Ass. Prof. Cornea/Uveitis service
College of Medicine, King Saud UniversityCollege of Medicine, King Saud University
Ocular EmergenciesOcular Emergencies
General Emergancies:General Emergancies:• Corneal ulcerCorneal ulcer• UveitisUveitis• Acute angle closure Acute angle closure
glaucomaglaucoma• Orbital cellulitisOrbital cellulitis• EndophthalmitisEndophthalmitis• Retinal detachmentRetinal detachment
Orbital/Ocular trauma:Orbital/Ocular trauma:• Corneal abrasionCorneal abrasion• Corneal and conjunctival Corneal and conjunctival
foreign bodiesforeign bodies• HyphemaHyphema• Ruptured globeRuptured globe• Orbital wall fractureOrbital wall fracture• Lid LacerationLid Laceration• Chemical injuryChemical injury
Corneal UlcerCorneal Ulcer
Corneal ulcer occur secondary to lid Corneal ulcer occur secondary to lid and conjunctival inflammation but it is and conjunctival inflammation but it is often secondary to trauma or contact often secondary to trauma or contact lens wearlens wear
Bacterial, viral, fungal or parasiticBacterial, viral, fungal or parasitic
Corneal UlcerCorneal Ulcer
Ocular pain, redness and discharge Ocular pain, redness and discharge with decrease vision and corneal with decrease vision and corneal opacity.opacity.
Corneal UlcerCorneal UlcerManagement: Management:
1.1. Prompt diagnosis of the etiology by doing Prompt diagnosis of the etiology by doing corneal scraping.corneal scraping.
2.2. Treatment with appropriate antimicrobial Treatment with appropriate antimicrobial therapy is essential to minimize visual loss.therapy is essential to minimize visual loss.
3.3. Then treat the inflammatory processThen treat the inflammatory process
4.4. Promote healing and treat the primary cause Promote healing and treat the primary cause if present (e.g. lid deformity, dryness)if present (e.g. lid deformity, dryness)
Contact lens wearerContact lens wearerAny redness occur for patients who wear contact Any redness occur for patients who wear contact lens should be managed with extreme cautionlens should be managed with extreme caution
Remove lensRemove lens
Rule out corneal infection (i.e corneal ulcer)Rule out corneal infection (i.e corneal ulcer)
gram negative organisms, fungi and Acanthembea gram negative organisms, fungi and Acanthembea are common causative organismsare common causative organisms
Do not patchDo not patch
Close Follow upClose Follow up
UveitisUveitisInflammation of the uveal tissue (iris, ciliary body, or Inflammation of the uveal tissue (iris, ciliary body, or choroid), retina, blood vessels, optic disc, and choroid), retina, blood vessels, optic disc, and vitreous can be involved.vitreous can be involved.EtiologyEtiology
IdiopathicIdiopathicInflammatory diseasesInflammatory diseases
• HLA B27, Ankylosing spondylitis, IBD, Reiter’s syndrome, HLA B27, Ankylosing spondylitis, IBD, Reiter’s syndrome, Psoriatic arthritisPsoriatic arthritis
• Sarcoidosis, Behcet’s, Vogt-Koyanagi-Harada SyndromeSarcoidosis, Behcet’s, Vogt-Koyanagi-Harada SyndromeInfectiousInfectious
• Herpes virusHerpes virus• ToxoplasmosisToxoplasmosis• TuberculosisTuberculosis• SyphilisSyphilis
UveitisUveitis
UveitisUveitis
UveitisUveitis
ManagementManagementIdentify possible causeIdentify possible causeTopical steroidTopical steroidTopical cycloplegicTopical cycloplegicSystemic immunosuppressive medicationSystemic immunosuppressive medication
• SteroidSteroid• CyclosporineCyclosporine• MethotrexateMethotrexate• Azathioprine Azathioprine • CyclophosphamideCyclophosphamide
Immunomodulating agentsImmunomodulating agents• Infliximab (Anti TNF)Infliximab (Anti TNF)
Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Result from peripheral iris blocking the Result from peripheral iris blocking the outflow of fluidoutflow of fluid
Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Present with pain, redness, mid-dilated pupil Present with pain, redness, mid-dilated pupil with decrease vision and coloured haloes with decrease vision and coloured haloes around lightsaround lightsSevere headache or nausea and vomitingSevere headache or nausea and vomitingIntraocular pressure is elevatedIntraocular pressure is elevatedCan cause severe visual loss due to optic Can cause severe visual loss due to optic nerve damagenerve damageMedical Tx and peripheral laser iridotomy will Medical Tx and peripheral laser iridotomy will be curative in most casesbe curative in most cases
Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Medical Tx and peripheral laser Medical Tx and peripheral laser iridotomy will be curative in most casesiridotomy will be curative in most cases
Preseptal CellulitisPreseptal Cellulitis
Preseptal CellulitisPreseptal Cellulitis• Lid swelling and erythemaLid swelling and erythema• Visual acuity ,motility, pupils, and globe are Visual acuity ,motility, pupils, and globe are
normalnormal
Preseptal CellulitisPreseptal Cellulitis
EtiologyEtiologySkin woundSkin woundLacerationLacerationRetained foreign body from traumaRetained foreign body from traumaVascular extension, or extension from Vascular extension, or extension from sinuses or another infectious site sinuses or another infectious site ( e.g.,dacryocystitis, chalazion)( e.g.,dacryocystitis, chalazion)OrganismsOrganisms• Staph aureus – Streptococci- H.influenzaeStaph aureus – Streptococci- H.influenzae
Preseptal CellulitisPreseptal Cellulitis
Management:Management:Warm compressesWarm compresses
Systemic antibioticsSystemic antibiotics
CT sinuses and orbit if not better or +ve CT sinuses and orbit if not better or +ve history of traumahistory of trauma
Orbital CellulitisOrbital Cellulitis
PainPain
Decreased visionDecreased vision
Impaired ocular motility/double visionImpaired ocular motility/double vision
Afferent pupillary defectAfferent pupillary defect
Conjunctival chemosis and injectionConjunctival chemosis and injection
ProptosisProptosis
Optic nerve swellingOptic nerve swelling
Orbital CellulitisOrbital Cellulitis
Management:Management:AdmissionAdmission
Intravenous antibioticsIntravenous antibiotics
Nasopharynx and blood culturesNasopharynx and blood cultures
Surgery maybe necessarySurgery maybe necessary
Orbital CellulitisOrbital Cellulitis
EndophthalmitisEndophthalmitis
Potentially devastating complication of Potentially devastating complication of any intraocular surgeryany intraocular surgery
Any patient in the early postoperative Any patient in the early postoperative period (within 6 weeks of surgery) c/o period (within 6 weeks of surgery) c/o pain or decrease vision should be pain or decrease vision should be evaluated immediatelyevaluated immediately
EndophthalmitisEndophthalmitis• ManagementManagement
– Vitreous sample for cultureVitreous sample for culture– Intravitreal antibiotics injection plus topical antibioticsIntravitreal antibiotics injection plus topical antibiotics
Retinal DetachmentRetinal Detachment
SymptomsSymptomsFlashes, floaters, a curtain or shadow Flashes, floaters, a curtain or shadow moving over the field of visionmoving over the field of vision
Peripheral and/ or central visual lossPeripheral and/ or central visual loss
Retinal DetachmentRetinal Detachment
Corneal AbrasionCorneal Abrasion
Corneal AbrasionsCorneal Abrasions
History of scratching the eyeHistory of scratching the eye
Symptoms:Symptoms:Foreign body sensationForeign body sensation
PainPain
TearingTearing
PhotophobiaPhotophobia
Corneal AbrasionsCorneal Abrasions
Treatment:Treatment:Topical antibioticTopical antibiotic
Pressure patch over the eyePressure patch over the eye
Refer to ophthalmologistRefer to ophthalmologist
Chemical InjuriesChemical Injuries
A vision-threatening emergencyA vision-threatening emergency
The offending chemical may be in the The offending chemical may be in the form of a solid, liquid, powder, mist, or form of a solid, liquid, powder, mist, or vapor.vapor.
Can occur in the home, most commonly Can occur in the home, most commonly from detergents, disinfectants, solvents, from detergents, disinfectants, solvents, cosmetics, drain cleaners…..cosmetics, drain cleaners…..
Chemical InjuriesChemical Injuries
Can range in severity from mild irritation Can range in severity from mild irritation to complete destruction of the ocular to complete destruction of the ocular surfacesurface
Management:Management:Irrigate with clean waterIrrigate with clean water
Instill topical anestheticInstill topical anesthetic
Check for and remove foreign bodiesCheck for and remove foreign bodies
Chemical InjuriesChemical Injuries
Immediate irrigation essential, preferably Immediate irrigation essential, preferably with saline or Ringer’s lactate solution, for with saline or Ringer’s lactate solution, for at least 30 minutesat least 30 minutes
Chemicals InjuriesChemicals Injuries
Irrigation should be continued until neutral Irrigation should be continued until neutral pH is reached (i.e.,7.0)pH is reached (i.e.,7.0)
Instill topical antibioticInstill topical antibiotic
Frequent lubricationsFrequent lubrications
Oral pain medicationOral pain medication
Enhance healingEnhance healing
Corneal and Conjunctival Foreign Corneal and Conjunctival Foreign BodiesBodies
• History of traumaHistory of trauma• Foreign body sensation-TearingForeign body sensation-Tearing
Corneal and Conjunctival Foreign Corneal and Conjunctival Foreign BodiesBodies
ManagementManagementInstill topical anestheticInstill topical anesthetic
Removal of the foreign bodyRemoval of the foreign body
Topical antibioticTopical antibiotic
Treat corneal abrasionTreat corneal abrasion
HyphemaHyphema• Can occur with blunt or penetrating injuryCan occur with blunt or penetrating injury• Blood in the anterior chamberBlood in the anterior chamber
HyphemaHyphema
Can lead to high intraocular pressureCan lead to high intraocular pressureDetailed history (Sickle cell)Detailed history (Sickle cell)ManagementManagement
Bed restBed restTopical steroidTopical steroidTopical cycloplegicTopical cycloplegicAntifibrinolysis agents (Tranexamic acid)Antifibrinolysis agents (Tranexamic acid)Surgical evacuationSurgical evacuation
Ruptured GlobeRuptured Globe• Suspect a ruptured globe if:Suspect a ruptured globe if:
– Severe blunt traumaSevere blunt trauma– Sharp objectSharp object
Ruptured globeRuptured globe
Suspect a ruptured globe if:Suspect a ruptured globe if:Bullous subconjunctival hemorrhageBullous subconjunctival hemorrhageUveal prolapse (Iris or ciliary body)Uveal prolapse (Iris or ciliary body)Irregular pupilIrregular pupilHyphemaHyphemaVitreous hemorrhageVitreous hemorrhageLens opacityLens opacityLowered intraocular pressureLowered intraocular pressure
Ruptured GlobeRuptured Globe
Bullous subconjunctival hemorrhageBullous subconjunctival hemorrhage
Ruptured GlobeRuptured Globe
Uveal prolapse (Iris or ciliary body)Uveal prolapse (Iris or ciliary body)
Ruptured GlobeRuptured Globe
• Irregular pupilIrregular pupil
Ruptured GlobeRuptured Globe
• Intraocular foreign bodyIntraocular foreign body
If globe ruptured or laceration is If globe ruptured or laceration is suspectedsuspected
• Stop examinationStop examination
• Shield the eyeShield the eye
• Give tetanus prophylaxisGive tetanus prophylaxis
• Refer immediately to ophthalmologistRefer immediately to ophthalmologist
Orbital FracturesOrbital Fractures• Assess ocular motilityAssess ocular motility• Assess sensation over cheek and lipAssess sensation over cheek and lip• Palpate for bony abnormalityPalpate for bony abnormality
Lid LacerationLid Laceration– Can result from sharp or blunt traumaCan result from sharp or blunt trauma– Rule out associated ocular injuryRule out associated ocular injury
Break TimeBreak Time