Ophthalmic emergencies

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Chapter 36 Ophthalmic emergencies

Michael R. Delaney, Iromi Samarasinghe

PRINCIPLES OF EXAMINATION

1. All cases of suspected eye injuries need a good history and examination of:

• visual acuity—visual loss sudden/gradual; central/peripheral; monocular/binocular
• pupillary reactions
• the fundus
• ocular movement
• fields to confrontation
• lids and ocular adnexae.

2. Do not put pressure on the eye to examine it (especially if there is a possible penetrating injury).
3. Do not use atropine drops to dilate the pupil. Use a short-acting mydriatic, e.g. tropicamide 1%, and only if essential.
4. Do not use mydriatics in cases where the ocular state and optic nerve function may need to be monitored.
5. CT scan or X-ray the orbits in all cases of a suspected intraocular foreign body, especially if the patient was using a hammer on metal, e.g. a chisel. Note: Request X-ray with eyes in up and down gazes.

COMMON PITFALLS

• Never use steroid drops in the emergency department in initial treatment. Refer for further assessment.
• Eye swabs need to be plated out directly.
• Avoid contaminated diagnostic medications. Use only sterile drop solutions.
• Always pad an eye after instilling local anaesthetic.
• Never give local anaesthetic drops to the patient to take away and use.
• Only use a short-acting cycloplegic, e.g. cyclopentolate 1% or homatropine 2%, if necessary.
• Do not apply ointment in cases of suspected penetrating injury.
• Do not persist in trying to remove a corneal foreign body if it is not easily removed—refer for ophthalmology review according to your hospital’s practice.
• Always provide adequate systemic analgesia in cases of corneal injury.
• When in doubt seek an ophthalmic consultation.

USE OF THE SLIT LAMP

These remarks apply to the Haag Streit slit lamp, but the principles apply to all slit lamps. The patient and the examining doctor must both be comfortable. In particular, the patient should not be straining to keep the chin on the chin rest, and the patient’s forehead must rest comfortably against the forehead strap. The eye should be at the level of the black mark on the side of the two columns that hold the chin rest and forehead strap; this is achieved by adjusting the height of the chin rest. The slit lamp should then be adjusted so that it is in its mid position, allowing a full range of vertical and horizontal movement. This position is adjusted by rotating the joystick which controls the height of the slit lamp as well as the movement of the slit lamp in all directions, thereby controlling its focus.

After the patient is positioned correctly, the eye can be examined. On the bottom of the rotating light source column of the slit lamp is a knob that controls the width of the slit beam. Further up the column, immediately under the globe housing, is a control to adjust the intensity of the light; this same control also allows the insertion of a cobalt blue filter into the light, producing the characteristic blue light used to detect corneal ulcers with fluorescein dye. Near this control is another control that adjusts the height of the slit beam.

The slit lamp can be used in many ways. The easiest is simply to use it as a high-powered illumination source with magnification using the broad beam; this is particularly useful to detect corneal ulceration after instilling fluorescein dye and using the cobalt blue filter. To detect and assess iritis, a narrow slit beam can be shone through the anterior chamber; this will highlight any flare or cells. A slit beam can be shone directly through the pupil to retro-illuminate the iris using the red reflex; this is also a useful way of assessing the clarity of the media.

Intraocular pressures are measured using the application tonometer, which is either attached to the slit lamp on a swinging arm or is detached from the slit lamp and is placed on the platform immediately in front of the eye pieces.

TRAUMA

Foreign bodies

Conjunctiva

Carefully examine posterior lid surfaces and fornices by everting the upper lid. Remove with moist swabstick or fine forceps.

Cornea

• Remove with a sterile swab stick or sterile 25-gauge needle. Do not attempt to remove rust ring. Apply antibiotic ointment and pad firmly.
• Patients with a residual rust ring and foreign body remnants must be referred.

Intraocular

• Always suspect if there has been an eye injury after using a metal hammer on metal, or where there have been high-velocity particles.
• There are often minimal signs. CT scan or X-ray of the orbit is mandatory.
• Treat as a penetrating injury and organise urgent ophthalmic consultation.

Corneal abrasions

• Examine the eye under cobalt blue light after instilling local anaesthetic drops (amethocaine 0.5%) and fluorescein.
• Check for subtarsal foreign body.
• Treat with chloromphenicol 1% antibiotic ointment and firm pad for 24 hours and provide adequate analgesia.

Lid lacerations

• All lid lacerations must be carefully assessed to exclude penetrating eye injury.
• Lacerations nasal to the punctum on either the upper or lower eyelids should be referred to an ophthalmologist to exclude damage to the nasolacrimal drainage system.
• Inspect punctum and look for lacerations to the canaliculus, which require prompt repair.
• Lacerations through the lid margin need meticulous repair to prevent lid notching. Refer to ophthalmology service according to your hospital’s practice.

Burns

Chemical: acid or alkali

1. Immediate irrigation with copious amounts of water or saline solution for at least 30 minutes until the pH neutralises to 7.5. Use universal indicator paper to check corneal pH after every litre of fluid irrigation.
2. If pain limits eye opening, instil local anaesthetic drops.
3. Alkali burns from lime, mortar and plaster are the most damaging of all chemical injuries. All particles of lime must be removed using a cotton bud or fine forceps. Evert lids to inspect fornices.

Acid burns commonly result from exposure to car battery fluid, toilet cleaners and pool cleaners.

4. All chemical burns should be referred to ophthalmology on the same day. Systemic analgesia is often required.

Thermal burns

Remove any obvious loose foreign bodies after instilling anaesthetic drops. Start antibiotic drops and pad if possible.

Flash burns

Symptoms appear hours after exposure to sunlamps or welding arcs without eye protection. These are intensely painful with blepharospasm, tearing and redness. Pain can start up to 6–12 hours after injury and last for 24 hours.

Examination is only possible after topical anaesthesia. Slit lamp examination with fluorescein will show widespread epithelial defects bilaterally.

Management

1. Apply chloramphenicol 1% ointment and pad. Cycloplegics may be needed to minimise severe eye pain (homatropine 5% BD for 3 days). Systemic analgesia and sedation are usually needed.
2. Review in 24 hours.

Blunt ocular trauma

Severe injuries can be easily missed. The history is not always a good guide to the severity of the injuries.

Subconjunctival haemorrhage

• The appearance is alarming. No treatment is needed except reassurance.
• Examine the eye to exclude any other injuries.

Hyphaema

Blood in anterior chamber following blunt trauma involving punch or cricket/squash ball to eye.

Management

1. Admit to hospital for bed rest, head elevation to 30–45° and limit eye movement with pad. Bed rest at home if circumstances are appropriate. Arrange for urgent ophthalmic consultation within 24 hours.
2. Provide adequate analgesia, avoiding aspirin.
3. Control intraocular pressure with beta-blockers, mannitol or acetazolamide after ophthalmic consultation.

Complications include: a more severe secondary haemorrhage in 30% of cases, 2–5 days after the initial bleed (especially in children); secondary glaucoma due to outflow obstruction; raised intraocular pressure (IOP); missed blowout fractures of orbit.

Traumatic mydriasis and iridodialysis

No treatment is available. Often associated with hyphaema.

Remember as a cause of abnormal pupillary reactions in cases with head and eye injuries.

Lens and retinal injuries

These need referral within 24 hours. See the section ‘Retinal detachment’ under ‘Sudden painless monocular visual loss’ below.

Vitreous haemorrhage and choroidal haemorrhage

Advise bed rest at home. Ophthalmology referral within 24 hours to exclude retinal detachment. See the section ‘Vitreous haemorrhage’ under ‘Sudden painless monocular visual loss’ below.

Orbital fractures and haemorrhage

Blowout fractures

Mechanism of injury involves punch or squash/cricket ball to orbit. Often associated with fractures of malar complex and middle third of face fractures.

Pain on vertical eye movement and local tenderness along orbital margin. Suspect if there is restriction of extraocular movement, enophthalmos or the patient complains of double vision. Assess infraorbital nerve involvement by testing sensation on unilateral cheek and upper incisors. The eye must be examined during initial assessment.

Investigations include CT scan of brain and orbital reconstructions (coronal views most useful).

Management

Admit if other injuries require treatment. Otherwise needs referral within 24 hours for evaluation of diplopia and enophthalmos. Start oral antibiotics (cephalexin 500 mg QID). Instruct patient not to blow nose and to avoid Valsalva manoeuvres in first week. Nasal decongestants for 7–10 days. Surgical repair is usually done after 7–14 days.

Orbital haemorrhage

• Is often associated with orbital fractures.
• Can be sight-threatening. Needs urgent consultation if severe or the patient has reduced vision, non-reacting pupils or ophthalmoplegia and proptosis.
• May need urgent orbital decompression.

Optic canal fractures

• Often cause total visual loss due to compression of the optic nerve. Diagnosed on CT scans of brain and orbits.
• Needs urgent referral to ophthalmic surgeon.

Penetrating injuries

• Suspect from history, especially hammering on metal.
• Examine very gently. Do not put pressure on the eye.

Management

1. Keep nil by mouth. Provide adequate parenteral narcotics with antiemetics. Check tetanus immunisation and update as appropriate. Start systemic antibiotics (ceftriaxone 1 g daily) and local antibiotic drops (do not use ointment). Gently shield (do not pad) the eye.
2. Obtain X-ray or CT scan of the orbit if there is any possibility of intraocular foreign body.
3. Admit to hospital for bed rest or refer for urgent ophthalmology review according to your hospital’s practice.

THE PAINFUL RED EYE

Acute conjunctivitis

Red inflamed eye, less congested towards the limbus. Often gritty with copious mucopurulent discharge in bacterial infections. Copious serous discharge in viral infections. Highly contagious.

Management

1. Swab for culture and polymerase chain reaction (PCR).
2. Start broad-spectrum antibiotic drops every 1–2 hours, e.g. chloramphenicol 0.5% drops or ciprofloxacin drops in contact lens wearers.
3. If viral conjunctivitis suspected, treat with antihistamine drops, e.g. Naphcon-A drops QID or other OTC preparation to reduce chemosis and itching.

Acute keratitis (herpes simplex)

• Painful eye often with blurred vision, diffuse conjunctival injection and watery discharge.
• Look for dendrite using fluorescein stain and cobalt blue light of ophthalmoscope. Branching dendritic pattern of herpes simplex ulceration of cornea will appear green.

Management

• Herpes simplex ulceration is treated with acyclovir 3% ointment 5 times a day for 14 days plus antibiotic drops 4 times a day. Do not patch due to risk of Pseudomonas infection. Refer for ophthalmology review on following day.
• In non-herpetic keratitis, start antibiotic drops 4–6 times a day.
• Refer for urgent ophthalmology review if history of contact lens use.

Herpes zoster ophthalmicus

• Shingles in trigeminal nerve distribution involving ophthalmic branch.
• Vesicular rash noted on forehead or upper eyelid. Hutchinson’s sign is a vesicle on tip of nose.
• On corneal exam ‘pseudodendritic’ ulcer may be seen.

Management

1. Treat with famcyclovir 250 mg TDS or acyclovir 800 mg 5 times a day for 7 days.
2. Ophthalmology referral if visual acuity affected or eye is red.

Acute iritis (uveitis)

• Dull pain, photophobia and red eye; ciliary injection (more injected near the limbus).
• Sluggish small pupil and blurred vision.
• Intraocular pressure is normal.

Management

1. Slit lamp examination essential: anterior chamber appears cloudy from cells and flare.
2. Dilate pupil with short-acting cycloplegic drops 3 times a day and local steroid drops 4–6 times a day.
3. Analgesia and dark glasses may be required.

Acute narrow-angle glaucoma

• Severe pain in unilateral red eye. Poor vision associated with headache, nausea and vomiting.
• Semidilated non-reacting pupil. Cornea appears hazy.
• Intraocular pressure is markedly raised. Eye is tender and tense to palpation.

The main differential diagnosis is acute iritis, which can cause secondary glaucoma.

Management

1. Urgent referral to ophthalmologist as this is a sight-threatening condition.
2. Start miotic drops—pilocarpine 2% every 5 minutes for 1 hour. Then hourly, plus timolol 0.5% twice daily plus prednisolone 0.5% 4 times a day.
3. Acetazolamide 500 mg IV, then 250 mg every 8 hours (orally if tolerated).
4. Narcotic analgesia for pain management, e.g. morphine 5–10 mg IMI.

Periorbital cellulitis

Periocular superficial cellulitis involving preseptal tissue. Eye not involved. Requires systemic antibiotics and observation. Usually due to Staphylococcus aureus or Haemophilus influenzae, in children with otitis media. Examination of the eye may be difficult due to marked swelling. In children, especially, may require examination under general anaesthetic to exclude eye involvement.

Orbital cellulitis

• Potentially life-threatening eye infection.
• Oedema and swelling of eyelids and conjunctiva. Often with proptosis, restriction of eye movement, dull pain and fever. There may be altered pupillary response and reduced visual acuity is a late sign. Usually secondary to trauma or orbital extension of paranasal sinusitis.
• Commonly due to Staphylococcus aureus, Haemophilus influenzae or Streptococcus pneumoniae.

Management

1. Swab any wounds, start high-dose IV antibiotics: dicloxacillin 2 g qid plus ceftriaxone 2 g daily in adults.
2. CT scan of orbits and paranasal sinuses to exclude cavernous sinus thrombosis.
3. Admit to hospital and observe the vision and the eye. Urgent ophthalmology referral.

SUDDEN PAINLESS MONOCULAR VISUAL LOSS

Amaurosis fugax

Sudden painless visual loss, usually partial and transient, due to embolic occlusion of retinal artery in transient ischaemic attack. Visual loss lasts minutes and returns to normal by the time of presentation to emergency department. Fundoscopic examination essentially normal.

Requires referral to neurologist for appropriate investigations, including echo, carotid duplex scans, cerebral perfusion scans and interventions in stroke management.

Retinal artery occlusion

• Sudden painless total or partial loss of vision, more often in the elderly. Fundoscopic findings: pale disc, retinal oedema, cherry red spot on the macula and narrowed arteries.
• Look for treatable cause, e.g. temporal arteritis or emboli.

Initial treatment

If seen within 2 hours of onset of symptoms:

1. Lower intraocular pressure with digital massage and IV acetazolamide 500 mg.
2. Attempt to dilate blood vessels by breathing carbagen (95% O2 and 5% CO2) via mask, or re-breathing from a paper bag.
3. Continue treatment for at least 30 minutes. Obtain urgent ophthalmology consultation for treatment options.
4. Do an urgent ESR to exclude temporal arteritis; if elevated, start systemic steroids—60–100 mg prednisolone daily PO.
5. Admit to hospital.

Retinal vein occlusion

• Sudden and painless loss of vision that is usually incomplete and variable. Commonly seen in elderly, diabetics and hypertensives.
• Fundoscopy shows dilated retinal veins with multiple haemorrhages throughout the retina; optic disc often swollen. Referred to as ‘blood and thunder’ fundus if severe.
• Urgent ophthalmology consultation.
• No treatment.

Retinal detachment

• Painless visual loss with partial field loss, after a recent history of visual flashes and floaters. More common in myopic and aphakic (lens extracted) patients; often occurs after blunt trauma.
• Grey, elevated veil-like retina seen. Red reflex is lost.

Management

• If macula still not detached, admit to hospital for bed rest and urgent ophthalmic assessment.
• If macula detached (visual acuity is reduced), refer for assessment within 24 hours.

Vitreous haemorrhage

• Often preceded by large black floaters. Vision may vary up to complete visual loss.
• Advise bed rest at home. Needs referral within 24 hours to exclude retinal detachment.

Optic neuritis

• Loss of vision over hours to days, usually painless but pain may occur with eye movement. Common presenting feature of multiple sclerosis. Variable visual loss, more frequently central field loss.
• Afferent pupillary defect and marked loss of red saturation, i.e. reduced visual acuity affecting colour and contrast vision.
• Examine for other focal neurological defects.
• Urgent ophthalmology referral for investigation, including MRI.
• No initial or urgent treatment, but may respond to intravenous corticosteroids or immune modulators after appropriate consultation. There is no indication for oral steroids.

OPHTHALMIC CONDITIONS NEEDING REFERRAL

Acute dacryocystitis. Treat with warm compresses and massage of tear sac. Start antibiotics.

Squints in children. Need to be seen by an ophthalmologist without delay. Cover test to diagnose.

Chronic glaucoma. Patient needs full assessment and institution of therapy. Refer without delay.

Meibomian gland cyst/abscess. Treat with hot compresses plus local antibiotic drops (oral antibiotics if severe). Refer.

COMMON OPHTHALMIC MEDICATIONS

Antibiotics. Availability and use varies from country to country. A routine course of treatment would be 1 or 2 drops, 4–5 times a day for 4 days. Intensive treatment needs drops every 1 or 2 hours during waking hours with ointment at night. Antibiotics suitable for initial treatment: sulfacetamide 10%; chloramphenicol 0.5%; gentamicin 0.3%; tobramycin 0.3%, ciprofloxacin.

Mydriatics. Fundal observation is best carried out using 1 drop of tropicamide 0.5% (Mydriacyl) and waiting about 15 minutes. Reverse with pilocarpine 2% drops.

Cycloplegics. Use short-acting preparations, e.g. cyclopentolate 1% or homatropine 2%, 1–3 times a day. Do not use atropine.

Miotics. Pilocarpine 2% is the most commonly used strength.

Glaucoma preparations. Timoptol maleate 0.25%, 0.5%; levobunolol 0.25%, 0.5%; lantanoprost; brimonidine tartrate; apraclonidine HCl; pilocarpine HCl 1%, 2%, 4%; acetazolamide 250 mg.

Local anaesthetics. Tetracaine hydrochloride 0.5% (available in minims); proxymetacaine hydrochloride 0.5%.

Antiviral agents. Acyclovir 30 mg/g ophthalmic ointment.

Non-steroidal anti-inflammatory agents. Diclofenac (Voltaren); ketoralac (Acular).

Steroids. Fluorometholone 0.1%; prednisolone 0.5%, 1%; dexamethasone 0.1%.

Frequency of use. Remember to tell the patient to wait 5 minutes between different drops.

RECOMMENDED READING

Fraunfleder F.T., Roy F.M. Current ocular therapy, 6th edn. Philadelphia: WB Saunders; 2008.

Kanski J. Clinical ophthalmology—a systematic approach, 6th edn. Oxford: Butterworth–Heinemann; 2007.

Rhee D.J., Pyfer M.F. The Wills eye manual, 5th edn. Philadelphia: Lippincott Williams & Wilkins; 2008.

Sehu W. Eye emergency manual: an illustrated guide. North Sydney: NSW Department of Health; 2007.

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