A significant proportion, generally around 6 % of the workload of the Emergency Department (ED), is made up of patients with ophthalmic problems (Ezra et al. 2005). Tan et al. (1997) found a lack of basic ophthalmic training for ED Senior House Officers leading to a lack of confidence on their part in the management of eye emergencies. This lack of confidence on the part of junior doctors is reflected in the nursing teams of many EDs, although Ezra et al. (2005) found that nurses were significantly more accurate than junior doctors in their assessment of ED patients, and combined with the apparent health of many ophthalmic patients, can lead to inappropriate management in the ED.

Being able to see and make a visual assessment of surroundings is taken for granted by most people and the sudden decline in or loss of sight is an extremely frightening experience. In the ED, patients attend with acute and chronic ophthalmic conditions of varying degrees of severity. For some, immediate intervention can be sight-saving. This chapter will equip ED nurses to assess, identify and initiate care for patients with common ophthalmic conditions. Knowledge of the anatomy and physiology of the eye and surrounding structures will aid nurses in using mechanism of injury, signs and symptoms to assess the patient’s condition. The chapter will address ophthalmic conditions in terms of assessment findings, which can be broadly categorized into two groups:

• trauma

• non-traumatic red eye.

Anatomy and physiology of the eye (Fig. 31.1)

Orbit

The orbit is a large bony socket that contains the eyeball or globe with its associated muscles, nerves, blood vessels, fat and most of the lacrimal apparatus. Each of the two orbits is roughly pyramidal in shape with the apex lying posteriorly. The orbit is made up of seven individual bones: the maxilla, palatine, zygoma, sphenoid, frontal, ethmoid and lacrimal bones.

Assessing ophthalmic conditions

History

As in any presentation, establishing the exact history of a patient’s condition is fundamental to making an accurate diagnosis. The history of the presenting problem should include:

• how long the patient has had symptoms for and whether they are getting worse

• rapidity and mode of onset (Box 31.1)

Box 31.1 Determining mechanism of injury

• Chemical involvement – identify type of chemical substance

• Force of injury and size of projectile

• Possibility of penetration – may be small and high speed

• What first aid has taken place?

• is vision reduced and to what degree?

• degree, type and location of pain

• is there any discharge, watering or photophobia?

• has the patient had this, or a similar problem before?

• are there any concurrent systemic problems?

• does the patient wear glasses/contact lenses?

Discussion of systemic problems and medication is important as it can point to possible ophthalmic problems. For example, there is a link between ankylosing spondylitis and uveitis, and a link between rheumatoid arthritis and dry eyes, and there are many ophthalmic side-effects of systemic drugs. The assessing nurse needs to investigate any pre-existing ophthalmic or other medical conditions. Of particular importance are conditions such as glaucoma, iritis (uveitis) and blepharitis; systemic conditions such as diabetes and rheumatoid arthritis; and any drug therapy, as all of these may affect the health of the eye.

Visual acuity

Assessment of visual acuity should be undertaken at initial assessment for any ophthalmic patient, before any other investigations or treatment, except irrigation or instillation of topical anaesthetic. The patient’s affected or poorer-seeing eye should be tested first, and the other occluded with a card or the patient’s hand. Any distance glasses should be worn. He should be asked to read down from the top of the Snellen chart, making an attempt at all possible letters. Visual acuity should be recorded as:

The number for this line is indicated on the Snellen chart, just above or just below the letters. If part of a line only is read, this may be recorded as the line above plus the extra letters, or the line below minus the missed letters. For example, if the patient reads the ‘12’ line except for one letter, at 6 m, it should be recorded as 6/12 – 1.

If the patient’s vision appears poor (less than 6/9), a pinhole (a small hole in a card or a commercial pin-hole) can be held in front of the eye to negate the effects of any refractive error. The visual acuity should be recorded with and without pinholes and a note should be taken of whether distance glasses or contact lenses are worn. If the patient is unable to read the top letter, the distance should be reduced until the patient can see the top letter on the chart, i.e., 5/60, 4/60, etc. to 1/60. If the patient cannot see the top letter at 1 m, it should be ascertained whether he can count fingers (CF), see hand movements (HM) or just perceive light (PL) at 1 m. Lack of light perception is recorded as NPL. Normal visual acuity is 6/6, but normal visual acuity for the patient may be less for a variety of reasons.

Problems in accurate visual acuity assessment may occur if the patient does not speak English or is not able to read. Strategies to overcome this may include:

• using a recognition chart so that the patient may match letters or shapes

• obtaining the services of an interpreter or family member to translate for the patient

• with children, using picture tests such as the Kay picture test and making the procedure into a game – this will usually encourage greater cooperation.

Patients who are in pain should have a drop of topical anaesthetic instilled so that any corneal pain is alleviated and the patient can cooperate more fully with the procedure, thus achieving an accurate visual acuity. Patients sometimes feel that this is a test that they have to pass and ‘cheat’ by looking through their fingers etc. It should be explained that the nurse is attempting to obtain an accurate assessment of their vision and that it is important that they are not tempted to make it seem better than it really is.

Examining the eye

Eye examination must be systematic. It is very easy to assume a diagnosis from the history and, in that way, miss less obvious problems. The eye should be examined from the ‘outside’ – the eye position and surrounding structures – working ‘in’ to consider the globe itself. Considerations for a thorough eye examination are given in Box 31.2.

Box 31.2 Systematic eye examination

The eyes

• Are they in their normal position for the patient?

• Is there any enophthalmos/exophthalmos?

• Is movement normal?

The lids

• Position – look for entropion (lid turning inwards) and ectropion (lid turning outwards)

• Integrity – look for lacerations

• Lash line – is it intact; is there any ingrowing lashes/crusting/infestation?

• Swelling – the whole or part of the lid/pointing onto the lid margin/one or both lids

Conjunctiva

• Integrity – look for lacerations

• Structure – is it smooth or are there follicles or papillae?

• Other features – conjunctival cysts, pterygia, pingueculae

• Inflammation – is it generalized or local?

• Subconjunctival haemorrhages

• Discharge – type

• Fornices (both lower and subtarsal area) – concretions or foreign bodies

Cornea

• Integrity – lacerations, abrasions, ulcers

• Clarity

• Foreign bodies

Anterior chamber

• Depth (the distance between the curved cornea and the iris) – generally equal in both eyes

• Contents, e.g., red blood cells – inflammation is difficult to see without a slit lamp

Iris

• Colour – may be dull if there is inflammation in the anterior chamber

• Integrity – iris changes may occur in both blunt and penetrating trauma

• Position – a deviated pupil may indicate a perforated eye

• Size and shape – smaller or larger than the fellow eye; round or oval?

• Reaction – to light and to near objects

Remember to compare the findings with the normal eye. What appears to be an abnormality may be bilateral and normal for the patient.

Equipment to aid assessment

An adequate eye assessment can be performed with minimal equipment. A bright light source, such as a pen torch or adjustable light, is essential for examination of the eye. Ophthalmoscopes are useful for retinal examination, but not for general examination as they only produce a small spot of light. Magnification is a useful aid, particularly in the hunt for foreign bodies. A hand-held magnifier, head loupe or ring light can be used. Cotton buds are used to evert the eyelids, remove foreign bodies and during irrigation.

Fluorescein drops or strips that stain damaged epithelial tissue are useful in examining abrasions. The stain is inserted and then the eye is viewed through a cobalt blue filter, as a penlight attachment, slit lamp or ophthalmoscope filter. While slit lamps (a binocular microscope for eye examination) offer the optimum provision for examination, they are expensive and not vital to initial assessment. Topical anaesthetic, such as tetracaine 1 % or oxybuprocaine 0.4 %, should be available in single-dose applications for pain relief and to facilitate examination. Proxymetacaine stings less on initial application and may be preferable, especially in children (Andrew 2006).

Contact lenses

If the patient is wearing contact lenses, the lens should be removed from the injured eye or from both eyes if inflammation or swelling is present. If possible, the patient should remove his own lens; each contact lens wearer develops his own way of doing it.

Removal of lenses

To remove hard lenses, the nurse should stretch the skin of the eyelid by pulling gently in a lateral direction from the outside corner of the patient’s eye. Once the skin is stretched, the nurse should push the upper and lower lids together using a finger from each hand. This movement catches the edges of the lens and breaks its suction to the cornea. Once this happens, the lens will fall out (Fig. 31.4). Alternatively, the nurse could put a (washed) index finger on the lens and gently move away from the cornea. The lids can then be used to lever the edge of the lens away from the cornea, and as the adhesion to the cornea breaks, the lens can be gently removed (Shaw et al. 2010).

Figure 31.4 Removal of hard contact lenses.

Hard lenses can also be removed using a specifically designed suction cup. The cup should be soaked in saline and then gently pressed against the contact lens. This forms a stronger suction than that of the lens to the cornea. The lens can then be lifted away from the eye. Other suction extractors must be squeezed before applying to the lens. The lens should be put into a labelled container with normal saline. If any significant corneal infection is present, such as an ulcer or abscess, the lens must be kept for microbiological culture.

Removal of soft lenses is demonstrated in Figure 31.5.

Figure 31.5 Removal of soft contact lenses.

Triage decisions

• priority one (red) – acute chemical eye injury; failure to act to dilute or neutralize chemical agents results in increased tissue damage and can lead to vascular damage and ischaemia and is therefore sight-threatening

• priority two (orange) – severe pain, penetrating eye injury or acute complete loss of vision; these presentations have the potential to be sight-threatening or result in further damage if not treated promptly

• priority three (yellow) – moderate pain, reduced visual acuity or inappropriate (where the history does not explain the findings as this can be an indication of a safeguarding issue)

• priority four (green) – recent mild pain, red eye, foreign body sensation, diplopia, recent problem/injury

• priority five (blue) – chronic complaint without acute exacerbation.

Ocular burns

Ocular burns may be divided most commonly into chemical, thermal and radiation (UV) burns.

Chemical burns

These are the most urgent category of ocular burns and causes may include alkalis, acids or solvents. Alkali burns are caused by substances such as sodium or potassium hydroxide, used as cleaning agents; calcium hydroxide, found in plaster and mortar; and ammonia, which is found in fertilizer and used in liquid form. Alkalis rapidly penetrate corneal tissue, combining with lipids in cell membranes, which results in cell disruption and tissue softening. A rapid rise in the pH in the anterior chamber may damage intraocular structures, and damage to vascular channels leads to ischaemia. Acids are less penetrating, and most damage is done during and soon after exposure. Acid substances combine with tissue, forming barriers against deeper penetration and localizing damage to the point of contact, although they can still be devastating. Acid burns are often due to car battery (sulphuric) acid or more complex organic and inorganic compounds. Solvent burns, although very painful, usually cause only transient irritation and damage. Thermal and/or contusion injuries due to the temperature or pressure of the chemical may be superimposed on the chemical injury (Marsden 1999a).

Primary management

A prompt and effective response to a chemical injury is vital to minimize tissue damage. One of the main determinants of ultimate outcome is duration of contact (Waggoner 1997), and as Glenn (1995) suggested, the initial treatment given by the nurse in the case of chemical eye injury may have more impact on the final vision than any subsequent care by the ophthalmologist.

Irrigation: The initial treatment of acute chemical injury involves copious irrigation to dilute the chemical and remove particulate matter. Irrigation should commence immediately, using whatever source is available and no time should be wasted in trying to find out what chemical was splashed into the eye (Marsden 2009). In a multi-centre trial, Moscati et al. (2007) found no difference in the efficacy of irrigation fluids and therefore, in the ED, the irrigating fluid of choice is normal saline (0.9 %) administered via a giving set to provide a directable and controllable jet. Sterile water is also used. The eyelids should be held open and contact lenses removed. A drop of topical anaesthetic should be instilled prior to irrigation to assist in patient compliance and minimize pain. All aspects of the cornea and conjunctiva (exposed by everting the upper lid) should be thoroughly irrigated. All particulate matter should be removed, by wiping with a cotton-tipped applicator if necessary.

Any delay in irrigation adds to the contact time and increases the risk of more severe injury. It is best to assume that any previous irrigation is inadequate and carry out adequate irrigation when the patient presents, unless a significant time has elapsed (hours) between injury and presentation. Specific irrigation time and fluid volume depend on the nature of the chemical and its physical state as well as the patient’s condition. Waggoner (1997) suggested that it is impossible to over-irrigate a chemically injured eye and recommended irrigation for 15–30 minutes and one to two litres of saline is generally sufficient.

The use of pH paper to check for adequate irrigation may be debated. In alkaline injury in particular, the chemical leaches out of the eye for a number of hours after injury, thus altering the pH. Delay in therapy of a number of hours until the pH is back to normal will delay healing. It is useful though if used before irrigation to determine the type of chemical involved and again later to check any progress in returning to a normal pH. When measured by sensitive experimental methods, normal pH of the conjunctival sac is 6.5–7.6 (Forrester et al. 1996) but when measured by touching pH measuring paper to the conjunctiva, it is most often near 8 (Adler et al. 1968). It must be remembered that a chemical may have a neutral pH and still cause injury. Ultimately then, indicator paper is no substitute for adequate irrigation. Following irrigation, the patient’s visual acuity should be checked.

Acute chemical eye injury is defined by Mackway-Jones et al. (2005) as injury by chemicals occurring in the last 24 hours. While this is true, and places the patient into a red triage category, this should lead to immediate further assessment rather than immediate irrigation. If there is still particulate chemical material in the eye after 24 hours, then it needs irrigation, but small amounts of liquid will have been irrigated by profuse tearing over that period of time and if a period of a few hours has elapsed between chemical exposure and presentation to an ED, and the pH of the conjunctiva is between 7 and 8 at initial assessment, there is little need for irrigation. After irrigation, pH should not be expected to be 7 and is more likely to stabilise around 8 (Sharma et al. 2006).

Ophthalmic management: All but the most trivial chemical injuries should be referred to an ophthalmologist. The eye may look deceptively normal due to tissue blanching and ischaemia, which needs urgent assessment and treatment.

Ophthalmic management usually includes:

• mydriatics, which are used to dilate the pupil, reduce pain due to ciliary spasm and prevent adhesions between the iris and the lens (posterior synechiae)

• topical antibiotics – prophylactic use prevents secondary infection

• topical steroids to reduce and control inflammation

• admission to hospital may be required.

Solvent injury

This may be seen after staining with fluorescein as punctate stains on the cornea. They may be treated with a mydriatic drop to dilate the pupil and chloramphenicol ointment to prevent secondary bacterial infection and aid comfort. They usually resolve very quickly.

Thermal burns

These usually involve damage to the lids and are often associated with facial burns. Treatment is similar to that of thermal burns elsewhere on the body. Thermal burns range from very mild corneal injury which may be treated as an abrasion, with dilatation of the pupil and chloramphenicol ointment, to devastating injury such as that caused by molten metal which may require reconstruction of the globe and surrounding structures. Thermal burns involving the lids should be referred due to the possibility of aberrant healing, leading to lid closure and mobility problems (see also Chapter 11).

Radiation burns

These are likely to be caused by ultraviolet light in the form of sun lamps or from welding equipment. The symptoms are similar, ranging from mild discomfort to severe pain, photophobia and lacrimation. The condition is usually bilateral and symptoms are delayed by 6–10 hours. Topical anaesthetic drops may be used to facilitate examination but should not be given to the patient to use at home. Treatment may include dilatation of the pupil and topical chloramphenicol ointment. The most affected eye may be double padded. The condition resolves spontaneously within 24–36 hours.

Patients who have been using a MIG welder may need a fundal check if there is any residual loss of visual acuity after epithelial healing. The intensity of the light produced by this type of equipment may cause retinal burns (Marsden 1999b).

Penetrating trauma

Intraorbital foreign bodies are frequently the result of high-velocity injuries with varying clinical presentations. Penetrating injuries and intraocular foreign bodies may cause eye damage by:

• disruption of the ocular tissues at the time of injury

• introduction of infection

• scar tissue formation (corneal, disrupting vision, retinal detachment caused by contracting scars inside the eye)

• reaction of the eye to foreign bodies – from organic material introducing infection or inflammation and from the deposition of pigments caused by degrading metal foreign bodies.

Large penetrating eye injuries are very obvious, but small perforations may be easily missed. The eye may look intact if the perforation is small and the wound may be sealed by iris tissue. It is very important, therefore, that a systematic eye examination is carried out and the particular circumstances of the incident are ascertained (Marsden 1996, 2009). Corneal perforations always leave a full-thickness scar, even if it is very small. Scleral perforations may be masked by overlying subconjunctival haemorrhage.

The use of Seidel’s test may help to identify a full-thickness laceration. This involves instilling a drop of fluorescein into the eye and watching for dilution of it from escaping aqueous. The cobalt blue filter will identify dark tracks in the bright fluorescence, from escaping aqueous.

Patients with penetrating trauma should be referred urgently to an ophthalmologist. Wounds with retained foreign bodies should be protected with a rigid shield such as a cartella shield or a gallipot. Retained foreign objects should not be removed from the eye. In the case of other penetrating injuries, the eye should be covered with a single pad, so no pressure is applied to the eye, and a cartella shield if possible. The patient should be cared for lying flat or sitting at around 30 degrees in order to reduce the possibility of further injury or loss of ocular contents. After consultation with the ophthalmologist, a single drop of unpreserved antibiotic drop (a chloramphenicol minim) instilled in the eye may be useful. Preserved drops or ointments should not be used as both are toxic to intraocular tissues. There should never be an occasion when both eyes are covered. This can lead to extreme distress and disorientation.

Poor prognostic factors associated with globe loss include a wound larger than 10 mm, injuries that involve the retina, initial visual acuity of less than 5/200 at time of injury, no light perception at the time of injury, pellet mechanism of injury, injuries from blunt objects (Ehlers et al. 2008, Lemley et al. 2008, Abrames & Folio 2012).

Lid trauma

The eyelids must be intact, in the correct position and without any disruption to their structure and function in order that the eyes are protected effectively. Repair of lid trauma may be a planned activity rather than an emergency procedure due to the good vascularization of the lids and associated structures. Lid trauma, unless very superficial, should be referred to ophthalmologists, who are best able to achieve the necessary functional and cosmetic results for the patient.

Major closed trauma

A direct blow to the eye from a blunt missile such as a clenched fist, squash ball or champagne cork may produce one or a combination of the following:

• ecchymosis (or black eye)

• hyphaema

• dislocation of the lens

• iridodialysis

• traumatic mydriasis or miosis

• traumatic uveitis

• traumatic angle recession

• posterior segment problems such as retinal oedema (commotio retinae), choroidal rupture and retinal detachment

• blow-out fracture of the orbital floor or nasal wall

• orbital apex trauma and optic nerve injury

• retrobulbar haemorrhage.

Patients with reduced vision following blunt trauma should be referred to an ophthalmologist.

It is important to recognize the possibility of ocular involvement after indirect trauma such as base of skull fractures, as well as from more direct trauma where the eyes themselves do not appear to be involved. Any apparent loss or reduction of vision after trauma should be taken very seriously and the patient should be referred to an ophthalmologist urgently in order to reduce preventable vision loss.

Ecchymosis

Ecchymosis is more commonly known as a ‘black eye’. It results from a blow to the orbit that leads to bruising and oedema of the eyelids. In itself, it is a relatively minor injury, treated with ice packs to relieve swelling. The force needed to cause this sort of injury may cause contusion or concussion injuries to any or all of the structures within the eye, as well as orbital rim or floor fractures. It is important, therefore, that the eye and surrounding structures are assessed carefully. The patient may be able to assist in opening the lids enough for the clinician to be able to assess the eye. This kind of injury is common is some sports, such as rugby and squash, however, nearly 90 % of all sports-related eye injuries can be prevented with adequate eye protection (Cass 2012).

Hyphaema

Traumatic hyphaema may only be detectable with a slit lamp, when red blood cells may be seen floating in the anterior chamber, or alternatively it may be visible with the naked eye, when blood may fill the whole of the anterior chamber. Its presence usually indicates significant intraocular trauma (Woodcock 2009). The signs and symptoms of hyphaema are:

• history of trauma

• reduced visual acuity

• reddish haze present diffusely through the anterior chamber, a settled layer of blood inferiorly or complete filling of the anterior chamber

• pain – due to raised intraocular pressure and other eye injury

• pupil irregular or poorly reactive

• drowsiness – particularly in children.

Admission may be necessary in the treatment of hyphaema in children, and in the treatment of large hyphaema with raised intraocular pressure in adults, but is rare and generally patients are advised to rest at home. Daily intraocular pressure monitoring by an ophthalmologist is usual, and treatment with agents such as acetazolamide, glycerol or mannitol may be indicated if the intraocular pressure is raised.

Patients who need to be transported to an ophthalmic unit should be transported sitting upright to allow the blood cells to settle and the visual axis to clear as pigment from haemolysed red blood cells may permanently stain the corneal endothelium and reduce vision.

Luxation or subluxation of the lens

A patient with a total dislocation of the lens or a partial dislocation (subluxation) can also present to the ED. It may be the result of trauma, hereditary, or associated with certain syndromes, such as Marfan’s syndrome (Shaw et al. 2010). Vision will be disturbed, but the degree of visual disturbance will depend on the degree of dislocation. If 25 % or more of the zonules of the lens are ruptured, the lens is no longer held securely behind the iris. The signs and symptoms of luxation or subluxation of the lens are:

• deepening of the anterior chamber due to tilting of the lens posteriorly – the anterior chamber may be shallow if the lens moves anteriorly

• pupil block – this may occur if the lens occludes the pupil

• a tremulous iris (iridodonesis).

The patient should be referred to an ophthalmologist. In general, if no complications occur dislocated lenses are best left untreated. If complications do occur, such as raised intraocular pressure, these are treated before lens extraction is attempted, as surgery in these instances is difficult.

Iridodialysis

This is the disinsertion of the iris base from the ciliary body and it is often associated with hyphaema. No immediate treatment is undertaken. Whether or not surgical intervention is undertaken depends on the effect of iridodialysis on visual acuity after a suitable recovery period.

Traumatic mydriasis or miosis

This may be present after blunt trauma. Additionally, the pupil may react only minimally to light, or not at all, and may have an irregular shape. This deformity is indicative of complete or partial rupture of the iris sphincter. It may be permanent or transient.

Traumatic uveitis

A mild inflammatory reaction of the iris and/or ciliary body is frequently seen after blunt trauma. The patient complains of aching in the eye and cells, and flare may be seen in the anterior chamber. Treatment is as for any uveitis, i.e., dilatation and topical steroids by an ophthalmologist.

Angle recession

Angle recession refers to a separation or posterior displacement of the tissues at the anterior chamber angle at the site of the trabecular meshwork. At least 20 % of patients with a hyphaema have some degree of angle recession and are followed up, as secondary glaucoma may eventually follow damage to the trabecular meshwork.

Cataract

A cataract is an opacity of the lens of the eye. It prevents light entering the lens properly and causes dimness of vision. When the structure of the lens is altered, e.g., as a result of a blunt (contusion) injury from a squash ball, aqueous enters the lens substance, causing it to swell and become cloudy. Contusion cataracts may occur as an immediate or long-term consequence of blunt trauma.

Posterior segment problems

A number of posterior segment problems may result from blunt trauma. Their common feature from the patient’s perspective is a reduction in visual acuity which may be relatively temporary, usually a matter of weeks, or permanent. It is not possible to give the patient an accurate prognosis for vision initially as this may take some time and early referral to the ophthalmologist is important.

Orbital fractures

The orbits are each composed of seven bones, the thinnest of which are the lamina papyracea over the ethmoid sinuses, along the medial wall, and the maxillary bone on the orbital floor.

Medial orbital fractures

The lacrimal secretory structures, especially the nasolacrimal duct, may be damaged and the medial rectus muscle may be trapped within fractures of the medial wall of the orbit.

Orbital floor fractures

These are often referred to as ‘blow-out fractures’ and are produced by transmission of forces through the bones and soft tissues of the orbit by an object such as a ball or fist. They typically may be found in young patients in their teens and twenties and may not be clinically obvious. Diplopia, nausea, and vomiting with no subconjunctival haematoma in a young patient requires immediate referral (Lynham et al. 2012). Fractures may be complicated by fat and muscle entrapment which limits ocular motility, causing double vision. They are often found by plain X-rays, but CT scans are used to investigate them further. Symptoms resolve without surgery in almost 85 % of patients, as oedematous tissues usually settle, freeing muscles and allowing correct motility (Egging 2009). Visual loss following trauma has a poor prognosis for recovery; however, evolving loss may be indicative of retrobulbar haemorrhage and is potentially treatable (Mackenzie & Gibbons 2011). Signs and symptoms of orbital floor fracture include:

• diplopia

• enophthalmos

• surgical emphysema

• infraorbital anaesthesia.

A sentinel presentation is that the patient attends the ED stating that he has had a blow to the eye and when he blew his nose, his eyelids swelled hugely. This indicates a facture between orbit and sinus and air blown into orbital tissues from the sinus. Antibiotics are indicated to prevent orbital infection from contaminated air from the sinus.

Orbital fractures are not considered an ocular emergency unless visual involvement or globe injury is present. Discharge instructions should include cautions about Valsalva’s manoeuvres, such as straining at stool and nose blowing. Antibiotics should be prescribed to prevent orbital cellulitis as air from sinuses contaminates orbital tissue.

Orbital apex trauma and optic nerve injury

Orbital apex fractures may result from both direct, non-penetrating trauma or from penetrating trauma such as large foreign bodies. A number of syndromes have been defined to describe different presentations which depend on the degree of injury to vascular and neural structures within the orbital apex.

Optic nerve injury may occur, often due to traumatic optic neuropathy from indirect trauma (such as fractures of the base of the skull). The nerve may be compressed by haematoma, damaged by foreign body or fracture, resulting in anything from minor trauma to the nerve to transection. Injury to the cranial nerves present in the orbit will present as double vision in injury to the III, IV and VI nerves and as sensory disturbance to the areas supplied by the trigeminal nerve (V). Visual acuity should be checked repeatedly in this group of patients and any reduction should prompt immediate referral to an ophthalmologist (Marsden 2006).

Retrobulbar haemorrhage

This may occur from direct or indirect trauma to the orbit and progress rapidly, resulting in pain, proptosis of the globe, lid and conjunctival swelling and congested conjunctival vessels with subconjunctival haemorrhage. An ophthalmologist should be involved immediately if the globe begins to proptose after trauma and CT or MRI scan may be required urgently. Visual acuity should be checked very frequently as reduction in acuity suggests compression of the optic nerve, and emergency decompression of the haemorrhage by lateral canthotomy (a horizontal incision at the lateral canthus, through skin and conjunctiva and then through the lateral canthal tendon, under topical anaesthetic) will be required to relieve this.

Minor trauma

The vast majority of eye injuries are relatively minor and involve the anterior segment only. It is important, however, to bear in mind the possibility of more major trauma and not to rule it out without a comprehensive examination. If it is assumed that the eye injury is likely to be trivial, sight-threatening injuries may easily be missed. The degree of pain following eye trauma is not a good indication of the severity of the injury. Corneal abrasions can be extremely painful, whereas a sight-threatening perforating injury may be virtually painless.

Traumatic subconjunctival haemorrhage

This is common after a variety of injuries and is, in itself, relatively minor. Fluorescein should be used to rule out a conjunctival laceration. The condition is self-limiting and does not require treatment. A traumatic subconjunctival haemorrhage which extends backwards so that the posterior border is not visible may be an indication of significant orbital trauma and may warrant further investigation if the history and other signs and symptoms are indicative of this. The patient should be reassured that the haemorrhage will resolve, usually over a period of weeks.

Corneal abrasion

Corneal abrasions are very common as the corneal epithelium is easily damaged. The damage to the cornea exposes superficial corneal nerves, causing tearing, eyelid spasms and pain. The degree of pain may be considerable and visual acuity is likely to be reduced. Providing the deeper layers of the cornea are not involved, there should be no visual impairment after the abrasion has healed. Topical anaesthetic may be needed in order to examine the eye effectively. The eye should be stained with fluorescein, and the extent of the abrasion documented.

Eye pain is difficult to control. The pain associated with a breach in the corneal epithelium has a component of ciliary muscle spasm which can be relieved, along with a degree of the patient’s pain, by the use of a dilating drop such as cyclopentolate 1 %. Topical non-steroidal anti-inflammatory (NSAI) drops provide a significant degree of effective pain relief for patients with corneal pain and are usually prescribed four times daily (Brahma et al. 1996).

Any breach in the corneal epithelium places the eye at risk of infection. A prophylactic antibiotic is necessary and chloramphenicol is usually the antibiotic of choice. Short courses of topical chloramphenicol do not appear to cause systemic side-effects (McGhee & Ananstas 1996) and it is considered to be a very safe drug, widely used throughout ophthalmology in the UK. In the treatment of corneal abrasions, this is often prescribed in ointment form, as this provides a lubricant layer over the eye that enables the lid to slide over the damaged epithelium, and is therefore much more comfortable for the patient. As the antibiotic is for prophylaxis rather than treatment of infection and the ointment base is for comfort, there is no need to prescribe a ‘course’ of antibiotics. When the abrasion is healed, the patient will know as the pain will have resolved. At that point, the antibiotic treatment may be stopped. Corneal abrasions generally heal within 48–72 hours. Abrasions which appear slow to heal or involve loose epithelium should be referred to an ophthalmologist.

In some instances, the cornea is at particular risk of infection, slow healing or recurrent abrasion. This is particularly the case in human, animal or vegetable material scratches. It is important, therefore, that the patient uses the antibiotic ointment at night for a period of 3–4 weeks to prevent this occurring. Follow-up visits are not usually necessary unless the abrasion is particularly large, involves the deeper layers of the cornea or the patient is a child. The patient should be reassured that a corneal abrasion usually heals and pain relief occurs within 24–48 hours (Kumar et al. 2012).

Conjunctival abrasion and foreign body

Foreign bodies do not often penetrate the conjunctiva and are therefore easily wiped off using a moistened cotton bud after instillation of topical anaesthetic. The resulting (and any concurrent) abrasion may be treated with antibiotic ointment. A pad is not usually necessary and the degree of pain experienced is much less than with corneal trauma.

Subtarsal foreign body

In this case, the patient often presents with a foreign-body sensation and a history of something falling or blowing into the eye. Management involves everting the upper lid using a moistened cotton-tipped swab. Any foreign material trapped underneath the lid may be wiped off with the swab. The eye should then be stained with fluorescein to rule out any corneal abrasion. If corneal abrasions are present, they are often linear, superficial and quite characteristic of this type of injury. If the corneal injury is minimal, a stat dose instillation of antibiotic ointment is usually sufficient. If larger abrasions are present, they should be treated as corneal abrasions.

Corneal foreign body

These commonly occur from grinding wheels and other industrial machines, from DIY and even windborne materials. The patient may present with a foreign-body sensation, especially when opening or closing the eye. The final resting place of an intraocular foreign body, and the damage caused by it depend on the size, shape and moment of the object at the time of impact and the momentum of the object at the time of impact, and the site of ocular penetration (Scott 2011). Superficial foreign bodies are often easily removed with a moistened cotton bud after instillation of topical anaesthetic. Dry cotton buds should not be used as they can stick to the corneal epithelium, which is moist, and this may result in a large abrasion, complicating the injury.

Impacted corneal foreign bodies need to be removed using the edge of a hypodermic needle (most commonly 21 gauge) held tangentially to the cornea with the hand supported on the patient’s cheek or nose. The needle may be mounted on a cotton bud or syringe for easier manipulation. After the initial removal of the foreign body, a rust ring often remains which must be removed completely. This is easier after 24–48 hours of treatment with antibiotic ointment; referral to an ophthalmic unit is recommended.

Removal of corneal foreign body with a needle is a procedure that must be carried out with extreme care. It is quite possible to penetrate the cornea with a needle and corneal scarring will result if the deeper layers of the cornea are damaged. This can cause visual problems if it involves the visual axis. It is therefore important that if the ED possesses a slit lamp, it is utilized for the removal of corneal foreign bodies so that both a high degree of magnification and support for the patient’s head are possible. ED staff may feel most comfortable removing only peripheral foreign bodies and referring on central ones. If in any doubt, the patient should be referred to an ophthalmic unit.

After removal of the foreign body, treatment is as for a corneal abrasion. Many patients have repeat visits for removal of corneal foreign bodies and treat them as something of an occupational hazard, although opportunities should still be taken to reinforce the need for adequate eye protection as it is most unlikely that one foreign body would penetrate the eye while another stayed on the cornea. X-ray examination is only indicated if there is a definite history of a high-speed foreign body hitting the eye, such as a hammer and chisel, and no foreign body can be found.

Eye pads

There is no evidence that padding the eye enhances healing; however, for many patients, padding can make the eye much more comfortable. The decision to pad the eye of a patient with a corneal abrasion should therefore be accompanied by the advice that if the pad makes the eye more comfortable, it can be left in place, without disturbance for 24 hours and then removed and antibiotic treatment commenced. If the pad makes the eye less comfortable, it may be removed and antibiotic ointment commenced immediately. In this way, those patients who can be helped by padding are, and others are not made worse by the indiscriminate application of eye pads (Marsden 2006).

A single pad will not keep the eye closed and further damage to the cornea may be caused by the surface of the pad. If padding is required, the following method should be used. Fold one pad in half and place over the closed eyelids after instilling the necessary medication. Place the second pad, flat, over the first and secure with two or three pieces of tape (Fig. 31.6). It is unnecessary to pad an eye merely because topical anaesthetic has been used. Anaesthetic drops last for only around 20–30 minutes and the risk of the patient sustaining any further injury because of the topical anaesthetic drop is minimal (Cheng et al. 1997).

Figure 31.6 Use of eye pads.

The ED nurse should not pad the eye of a patient who is driving home. If the patient leaves the eye pad on and drives anyway, he is breaking the law, invalidating his insurance and is a danger to other road users. A drop of topical anaesthetic will facilitate driving home safely and the patient may then pad the eye at home.

Eye drops

Topical anaesthetic drops are a valuable tool for examination purposes. They ‘magically’ remove all the patient’s pain and he may be very keen to have some to take home so that this pain-free state may continue. Unfortunately, topical anaesthetic drops also inhibit epithelial healing. The patient will be pain-free, but the epithelial defect will not heal (Andrew 2006).

Topical non-steroidal anti-inflammatory drugs (NSAIDs) have been evaluated for use in corneal pain (Brahma et al. 1996) and found to be extremely useful. Their use does not appear to delay healing and no adverse effects have been found. A number of NSAIDs are available in eye drop form, including diclofenac sodium, flurbiprofen sodium and ketorolac trometamol.

Mydriatic and cycloplegic drops, such as cyclopentolate, dilate the pupil and paralyze accommodation. The patient’s near vision is therefore blurred for a period. This does not mean that the patient should not drive. If he feels safe to do so, there is nothing to stop him driving, as the legal standard for driving only includes distance vision and distance vision is not affected by dilatation. Near vision, which is affected, is not used to any great extent for driving. However, he should be warned that, if it is a bright day, he may be quite dazzled by sunlight and should wear sunglasses and take extreme care.

Steroid drops should not be prescribed in the ED as the effects of steroids on the eye in a misdiagnosed condition can be catastrophic.

Red eye

Ophthalmic trauma is fairly easy to recognize with the aid of a history and a brief eye examination. However, ophthalmic medical problems are, on the whole, less easily diagnosed and therefore may be dealt with less well than other problems. The differential diagnosis of the red eye (Marsden 2006) is shown in Table 31.1.

Table 31.1

Differential diagnosis of the red eye

Subconjunctival haemorrhage

Patients may present with a spontaneous subconjunctival haemorrhage. The patient may not have noticed any irritation and is often prompted to attend by others noticing the haemorrhage, which presents as a deep red patch of blood under the conjunctiva. It may be quite small and circumscribed or may be severe enough for the conjunctiva to protrude like a ‘bag of blood’. Providing there is no history of trauma, no treatment is needed except reassurance. Patients with clotting disorders or those on anticoagulants may be prone to repeat episodes. Subconjunctival haemorrhages will take up to three weeks to resolve and the blood may spread under the conjunctiva and actually appear worse before it begins to resolve.

Blepharitis

This chronic eyelid condition is very common. The patient is likely to present with gritty, sore eyes and red-rimmed eyelids with crusting, which may be mild to very severe, along the lid margin – the lash line. Treatment involves regular lid cleaning, using a cotton bud dipped in a solution of baby shampoo and water to ‘scrub’ the lid margin along the lash line to remove all the crusts. When the condition is acute, antibiotic ointment should be rubbed into the lid margin after lid hygiene two to four times a day. As this is a chronic condition, lid cleaning should continue even after the symptoms have resolved, or the condition will recur. Occasionally, punctate staining may occur at the corneoscleral junction. This is marginal keratitis, an inflammatory change. The patient should be referred to an ophthalmologist.

Conjunctivitis

Inflammation of the conjunctiva is by far the most common cause of red eyes. Bacterial conjunctivitis in adults is uncommon (Tullo & Donnelly 1995) and most conjunctivitis in adults is viral. Conjunctivitis in children is more likely to be bacterial.

Bacterial conjunctivitis

The patient is likely to present with a red, irritable eye, describing the sensation as ‘gritty’ rather than painful. Discharge is likely to be purulent and profuse, and the lashes may be coated with it. There will be no corneal staining with fluorescein. Treatment is usually with a broad-spectrum antibiotic such as chloramphenicol or fusidic acid, applied topically in the form of drops. Drops are often prescribed quite frequently during the first 48 hours; for example, in the case of chloramphenicol drops, two-hourly application would not be unreasonable.

Health education information, particularly on how to control the spread of infection, should be given and the nurse must ensure that the patient understands how to use his medication before leaving the ED. Information on how to keep the lids clean and free from discharge may be needed, e.g., using cooled, boiled water and cotton wool or tissues, especially by parents of small children who may also need extra help instilling the prescribed medication effectively. Patient education should also, where appropriate, incorporate discussion of cross-contamination through eye makeup, pillows and towels (Egging 2009).

Viral conjunctivitis

Viruses, often types of adenovirus, are by far the most common cause of conjunctivitis in adults (Kaufman 2011). Once again, the patient is likely to complain of a gritty sensation, but the discharge is much less likely to be purulent than profuse watering, with stickiness often only in the morning when the watery discharge has dried and the lids are stuck together. If the lid is everted, the conjunctiva covering it will appear very bumpy rather than smooth. These ‘bumps’ are follicles and are inflamed lymphoid tissue. This roughness of the conjunctiva is what makes the eye feel so gritty and irritable. The patient with viral conjunctivitis often complains of dryness, along with a watery eye. The tears, although profuse, are inadequate in quality and dry up very quickly; the eye responds to the irritation and dryness by producing more. There may be punctate erosions on the cornea when stained with fluorescein.

Some types of adenovirus, of which there are about 30, cause upper respiratory tract infection and this, when combined with an eye infection, is known as pharyngoconjunctival fever. The patient may feel generally unwell with flu-like symptoms and the preauricular lymph node may be enlarged. Treatment of viral conjunctivitis is based on controlling the symptoms. Unless the eye is particularly sticky, antibiotics are not indicated. Artificial tears may help to control the feeling of dryness and irritation and these may be used very frequently, e.g., every 30 minutes. A bland ointment such as simple eye ointment may also be helpful. Cold compresses on the lids may ease the irritation of this very distressing condition. The patient should be aware that viral conjunctivitis may persist for 3–6 weeks and the symptoms of dryness may last much longer.

Adenoviral conjunctivitis is a condition with symptoms out of all proportion to its relative clinical importance. Once the symptoms have peaked, however, the patient may be said to be no longer an infection risk. Adenovirus is highly infectious and infection control is of paramount importance, both for the patient and for the department. Hand washing is the first line of defence in infection control and is vital to stop the spread of viral conjunctivitis. Swabs to identify specific organisms are not required. Results do not change treatment and the swab is both painful and costly.

Chlamydial conjunctivitis

A patient presenting with a uniocular, chronic conjunctivitis causing only mild symptoms may have a chlamydial infection. A swab should be taken for culture and chlamydial identification and the patient referred to genito urinary medicine if the swab proves positive.

Allergic conjunctivitis

Allergic conjunctivitis is very common and presents acutely in two distinct ways. Firstly, the patient may have red eyes with itching and watering and an appearance of large bumps (papillae) on the subtarsal conjunctiva. This presentation is particularly common during spring and summer – the ‘hay fever’ season – and may also be associated with a runny nose, sneezing, etc. Treatment is with systemic antihistamines and/or topical antihistamine treatment such as emedastine or olopatadine. Topical mast cell stabilizing drops such as sodium cromoglycate are of little value in an acute exacerbation but may be useful if used throughout the whole of the ‘hay fever’ season by patients who are aware that they are likely to develop allergic conjunctivitis.

The second allergic presentation is an acute and frightening atopic reaction that involves massive swelling of the conjunctiva (chemosis) which the patient often describes as ‘jelly’ on the eye. This is usually due to the patient rubbing the eye with an allergen present on the hand or finger. Common allergens include some plant juices and cat hairs, although it is unlikely that the particular allergen will be identified. This condition is completely self-limiting and requires no treatment unless the chemosis is severe and protruding from the closed lids. In this case, lubricant drops may be helpful to prevent drying. Adequate reassurance is needed and, if the reaction is severe, the patient may need to be monitored for systemic effects of the allergen.

Anterior uveitis (also known as uveitis, iridocyclitis, iritis)

Uveitis is an inflammatory condition of part or all of the uveal tract (iris, ciliary body and choroid) (McDonald et al. 2012). It may be associated with systemic disease such as ankylosing spondylitis but which is often idiopathic. It may also occur secondary to trauma. The most common presentation is anterior uveitis (inflammation of iris and ciliary body, also commonly known as iritis). Common presenting symptoms are photophobia, pain due to iris and ciliary spasm, conjunctival redness (injection), which may be more marked around the corneoscleral junction (limbus), and decreased visual acuity. The reduction in vision is due to protein and white blood cells (part of the inflammatory response) in the anterior chamber. The pupil, because of spasm and inflammation, is likely to be small (miosed) compared with the unaffected eye and may react sluggishly. There will be a clear reflection of light when a light is shone onto the cornea, demonstrating the lack of corneal involvement, and there will be no staining with fluorescein. Prompt referral to an ophthalmologist is required and treatment is with topical corticosteroids, and mydriatics to dilate the pupil to reduce inflammation and prevent adhesions of the iris and lens.