Ophthalmologic Emergencies

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Chapter 46 Ophthalmologic Emergencies

Kathy Palmer, MD

1 What is an afferent pupillary defect?

The pupillary light reflex is a reflex arc through the midbrain involving crossover innervation. It is assessed with the swinging light test: Shining a light in one eye should result in constriction of both pupils. No change in pupillary size should be noted when the light swings toward the other pupil. If a patient has an afferent pupillary defect, both pupils dilate when the light swings to the affected eye. The abnormal pupil, called a Marcus Gunn pupil, can result from retinal artery or venous occlusions, retinal detachment, tumors, or ischemic optic neuropathy.

Wright KW: Pupil and iris abnormalities. In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 139–149.

2 What is the Bruckner test? How is it performed?

The Bruckner test is a simultaneous bilateral red reflex test that elicits both a corneal light reflex and a red reflex. View the patient’s eyes from about 2 feet away with a broad beam of light that encompasses both eyes. You should see both a red reflex and a small white light reflex in each eye. The key to a normal examination is symmetry. An absent or dull red reflex may indicate vitreous hemorrhage, cataract, hyphema, opacity of the cornea, enophthalmos (backward displacement of the globe in the orbit), or misalignment of the globe.

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

3 What is the differential diagnosis of papilledema?

Papilledema is caused by anything that increases intracranial pressure. It is usually bilateral.

image Increased cerebrospinal fluid production

image Decreased cerebrospinal fluid absorption

image Intracranial mass

image Obstruction of venous outflow

image Obstructive hydrocephalus

image Idiopathic intracranial hypertension (pseudotumor cerebri)

Giovannini J: Papilledema: www.emedicine.com

4 List and describe briefly the four types of orbital wall fractures

image Medial wall fractures are caused by blows to the bridge of the nose. Physical findings include orbital emphysema, epistaxis, depressed nasal bridge, and enophthalmos (sunken eye). Excessive tearing may be seen if the lacrimal system is disrupted.

image Orbital floor (“blowout”) fractures result when an object larger than the orbital diameter, often in the inferior lateral orbital rim, impacts the bony orbit. The impact causes increased intraorbital pressure and rupture of the orbital floor, which often is associated with prolapse of orbital contents into the maxillary sinus. Entrapment of the inferior rectus muscle causes limitation of upward gaze. Infraorbital nerve injury causes hypesthesia of the ipsilateral cheek and upper lip. Traumatic optic neuropathy can complicate an orbital floor fracture with immediate loss of vision and afferent pupillary defect.

image Superior wall (orbital roof) fractures are less common than medial or floor fractures but they are potentially life-threatening. They may be associated with central nervous system injury, pneumocephalus, or intracranial foreign body. Potential complications include brain abscess and meningitis. Findings include rhinorrhea (cerebrospinal fluid leak) and superior and lateral subconjunctival hemorrhage.

image Tripod fractures involve the zygomatic arch and its lateral and inferior orbital rim articulations. Examination findings are similar to those of orbital floor fractures, along with limitation of mandibular movement and trismus.

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

Widell T: Fractures, orbital: www.emedicine.com

5 How are orbital fractures managed?

Therapeutic interventions for any orbital fracture include antibiotic prophylaxis, nasal decongestants, and ice packs; some fractures may require surgical intervention. Computed tomography of the orbit, including axial and coronal views, is useful in diagnosis and delineating the extent of injury. All patients should be cautioned to avoid blowing their nose. Consultation with an ophthalmologist is indicated.

Levin AV: Eye trauma. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2000, pp 1485–1496.

Widell T: Fractures, orbital: www.emedicine.com

6 What is the difference between monocular and binocular diplopia?

Binocular diplopia resolves when either eye is covered. With monocular diplopia, double vision is present even when one eye is covered.

7 What causes binocular and monocular diplopia?

The causes of binocular diplopia include blowout fracture, traumatic cranial nerve palsies, iris injuries, inflammation, neoplasm, and strabismus. The causes of monocular diplopia include uncorrected refractory error, cataract, displaced lens, and conversion disorder.

8 What are “raccoon eyes”? What causes them?

Raccoon eyes result from eyelid ecchymoses, which classically are associated with basilar skull fractures. Subcutaneous bleeding occurs in the area around the orbits.

9 List the eye emergencies that warrant ophthalmologic consultation

image Ruptured globe

image Orbital hematoma

image Severe chemical burns

image Hyphema

image Retinal/vitreous detachment

image Intraocular foreign bodies

image Contact lens abrasions

image Complicated eyelid lacerations

10 What is the Seidel test? How is it performed?

A fluorescein strip touched to the lacerated area of the eye will show a stream of fluorescein, indicating an active leak of aqueous humor and full-thickness injury to the eye. A negative Seidel test does not exclude full-thickness injury because small injuries can self-seal. Full-thickness lacerations should be treated with a rigid eye shield and emergent ophthalmologic consultation.

11 While attempting to repair a superficial forehead laceration, some of the cyanoacrylate glue drips into the child’s eye and his lashes are stuck together. How should this patient be managed?

Cyanoacrylate glue rarely causes a serious injury to the eye. Usually, the child manages to close the eye as the glue approaches and the lashes may be stuck together, but the eye is generally unharmed. The lashes can be separated by applying mineral oil or petroleum jelly to the glued area and allowing this to remain in place for 30–60 minutes. It is important to be patient and not to forcefully pull the lids apart. Use of gentle friction with a cotton swap may be helpful. Avoid the use of acetone to dissolve the glue as this could injure the eye. Ophthalmologic consultation is rarely needed.

12 A teenager who was not wearing protective eyewear reports a “foreign body sensation” in his eye after hammering (metal on metal). How should this patient be managed?

With this history, the emergency physician should be suspicious of an intraocular foreign body that penetrated the cornea or sclera. The physical examination of the eye can be deceiving because the globe heals quickly and a laceration may not be visualized. Subtle signs, such as red eye, pupil asymmetry, and decreased vision, may be noted. However, small particles that rapidly penetrate the eye may produce few or no signs, and a high index of suspicion is needed. Consult the ophthalmology service urgently. Consider computed tomography to look for a foreign body (not magnetic resonance imaging if the foreign body might be metallic).

Neylan V, Eilbert WP: Ocular emergencies. Foresight 43; 1998, pp 1–8.

Selbst SM: Pediatric emergency medicine legal briefs. Pediatr Emerg Care 18:133–136, 2002.

13 How is a hyphema classified?

A hyphema is a collection of blood in the anterior chamber of the eye caused by compression of the eyeball and tearing of the anterior ciliary body. Hyphemas are classified by estimating the volume of the anterior chamber of the eye that is occupied by blood:

Grade I: <⅓ Grade III: > ½
Grade II: ⅓–½ Grade IV: complete

The higher the grade of the hyphema, the greater the risk for rebleeding (15% in grade I, 60% in grades II and III).

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

14 Who should you consider hospitalizing for treatment of a hyphema?

image Patients with hyphemas > of the anterior chamber

image Patients with evidence of increased intraocular pressure

image Patients with sickle cell disease

image Patients in social situations that preclude close outpatient follow-up

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

Sheppard J: Hyphema: www.emedicine.com

15 What is an “8-ball” hyphema?

The entire anterior chamber of the eye is occupied by blood, resembling the 8-ball in pool.

16 Why is a burn from an alkali more damaging to the eye than an acid burn?

The pH of the chemical that splashes in the eye is related to severity of injury. Alkali solutions tend to be more damaging because they penetrate more deeply. Acidic solutions coagulate proteins in the superficial layers of the eye, forming a protective barrier against further penetration. The severity of the injury is also related to the volume and duration of exposure.

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

Chen A: Burns, ocular: www.emedicine.com

17 Which corneal abrasions are most worrisome? Why?

Corneal abrasions over the visual axis, abrasions in patients with a history of ocular herpes, and corneal abrasions in contact lens wearers. Abrasions caused by contact lens use predispose the patient to fungal and bacterial infections and corneal ulceration.

18 Which of the following therapeutic interventions are indicated for the treatment of corneal abrasions?

A. Eye patching

B. Topical mydriatics

C. Topical antibiotics

D. Topical nonsteroidal anti-inflammatory drugs

E. Topical anesthetics

Answer: C and D. Traditional therapies for corneal abrasions have included eye patching and topical mydriatics. Current recommendations are based upon the results of randomized controlled trials. These studies showed that:

1 Patching did not improve healing time or pain. Patching can also cause increased difficulty in walking in pediatric patients. It also decreases oxygen delivery, increases moisture, and thereby brings a risk of infection.

2 Topical mydriatics were used to treat pain from ciliary spasm. A randomized controlled trial showed that pain was similar with or without mydriatics.

3 Topical anesthetics have never been indicated after the initial eye examination.

Current treatment recommendations include the use of topical antibiotics and pain control with either topical or oral analgesics. Patients using topical nonsteroidal anti-inflammatory drugs (NSAIDs) reported greater relief from pain and other symptoms. Examples of topical NSAIDs include diclofenac (Voltaren) and ketorolac (Acular). Some clinicians use prophylactic topical antibiotics for treatment of corneal abrasions. Ointments are more lubricating than drops. Antipseudomonal coverage should be used in contact lens wearers, and lens use should be discontinued until the abrasion is healed and antibiotic therapy is complete.

Wilson SA: Management of corneal abrasions Am Family Physician 70:123–128, 2004.

Weaver CS, Terrell KM: Evidence based emergency medicine update. Do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasions without delaying healing? Ann Emerg Med 41:134–140, 2003.

19 What are the symptoms of retinal detachment?

A retinal detachment is a separation between the sensory and pigment portions of the retina. Symptoms include “flashes,” “floaters,” and visual defects. Flashes of light are caused by traction at the peripheral retina. Floaters are caused by fibrous aggregates on the posterior portion of the vitreous that block light to the retina. Blurred vision and a dull red reflex are caused by vitreous hemorrhage. All patients who report flashes or floaters should be evaluated by an ophthalmologist to prevent progression of partial retinal tears to complete detachment. Traumatic damage to the retina often is located at the periphery of the retina, an area that is not easily examined with a direct ophthalmoscope. Any significant blunt eye trauma warrants evaluation by an ophthalmologist.

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

Larkin GL: Retinal detachment: www.emedicine.com

20 What are the symptoms of lens dislocation?

Symptoms of subluxation/dislocation of the lens include monocular diplopia, glare, and decreased visual acuity. A classic sign of lens dislocation is a tremulous iris. If the lens edge lies within the visual field, it may cause monocular diplopia or astigmatism. Lens subluxations may remain asymptomatic for weeks after the initial trauma, thereby making them difficult to diagnose. Rupture of the lens capsule rapidly results in cataract formation.

Eifrig C: Ectopia lentis: www.emedicine.com

Garcia SE, Hickey R, Santamaria JP: Pediatric ocular trauma. Pediatr Emerg Med Rep Oct:87–98, 1998.

21 Which sports are associated with a high risk for eye injuries?

image Paintball and air rifle or BB gun

image Basketball

image Baseball/softball

image Cricket

image Lacrosse

image Ice, field, and street hockey

image Squash and racquetball

image Fencing

image Boxing, wrestling, and full-contact martial arts

Committee on Sports Medicine and Fitness in Pediatrics: Protective eyewear for young athletes. Pediatrics 113:619–622, 2004.

22 How are bungee cords related to eye emergencies?

Eye injuries resulting from bungee cords are becoming increasingly common. The bungee cords are elastic with metallic hooks at either end (sometimes padded). They are often used in occupational and recreational settings. They can snap back with tremendous force and cause blunt and penetrating trauma to the eye. In a study at Wills Eye Hospital in Philadelphia, the most common related injuries were hyphemas (63%), but 10% of patients had sustained open globe injuries and some required enucleation.

Aldave AJ, Gertner GS, Davis GH, et al: Bungee cord associated ocular trauma. Ophthalmology 108:788–792, 2001.

23 What are the current recommendations for use of protective eyewear in athletes?

Appropriately fitted protective eyewear has been shown to decrease the incidence of injury by 90%. The American Academy of Pediatrics and the American Academy of Ophthalmology recommend eye protection for all athletes and mandate it in functionally one-eyed patients and in patients whose ophthalmologist recommends eye protection after surgery or trauma. Functionally one-eyed is defined as best corrected visual acuity of less than 20/40 in the weaker eye.

Recommendations for the appropriate protective eyewear for each sport can be found in the American Academy of Pediatrics policy referenced below and on the website for the Protective Eyewear Certification Council.

Committee on Sports Medicine and Fitness in Pediatrics: Protective eyewear for young athletes. Pediatrics 113:619–622, 2004.

Protective Eyewear Certification Council. Available at: www.protecteyes.org

Prevent Blindness America. Available at: www.preventblindness.org

24 What is the best solution to use for ocular decontamination after a chemical injury?

Traditional first aid teaches that tap water is an acceptable irrigant for immediate treatment of a foreign body or chemical in the eye. In the emergency department setting, the most common irrigant is normal saline solution (pH, 4.5–6.0). Other acceptable alternatives include lactated Ringers solution (pH, 6.2–7.5), buffered normal saline (pH, 7.4), and balanced salt solution plus (BSS Plus; pH, 7.4). Theoretically, irrigation solutions with a more neutral pH will provide less discomfort during prolonged irrigations.

Saidinejad M: Ocular irrigant alternatives in pediatric emergency medicine. Pediatr Emerg Care 21:23–26, 2005.

KEY POINTS: EYE TRAUMA

1 Always attempt to document the visual acuity in assessing a patient with a complaint related to the eye.

2 Emergent consultation with an ophthalmologist is indicated for any patient with a potentially ruptured globe. Place a rigid eye shield and keep the patient calm and receiving nothing by mouth.

3 Appropriately fitted protective eyewear can reduce the risk of ocular injury by 90%.

4 Patients with hyphemas should have the head of their bed elevated to facilitate settling of blood in the anterior chamber.

5 Patients with potential orbital fractures should be cautioned to refrain from blowing their nose.

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