Ocular emergencies

Lecture from penang medical college on ocular emergencies

1. OCULAR EMERGENCIES
DR. LEOW THYE YNG
BSc(Hons), MB BCh BAO (NUI),
MCOptom, MRCOphth,
FRCS(Glasg).

2. Ocular Emergencies
•Physical Injuries
•Chemical Injuries
•Infections
•Painless Sudden Loss of Vision
•Others - Acute Glaucoma
- Uveitis
- Painful CNIII Palsy

3. Ocular Emergencies
•1) PHYSICAL Injury - Superficial
- Blunt
(Closed or Rupture)
- Penetrating
(Laceration)
- Perforating
(Entry/Exit wounds)
- Foreign Body

4. Ocular Emergencies 2
•2) Chemical Injury
•3) Infection - Corneal Ulcer
- Corneal Abscess
- Endophthalmitis
•4) Painless Sudden Loss of Vision
- Retinal Detachment
- Central or Branch Retinal
Arterial Occlusion
- Giant Cell (Temporal) Arteritis

5. Ocular Emergencies 3
•5) Acute Glaucoma
•6) Uveitis
•7) Painful CNIII Palsy

6. Ocular Emergencies 4
•Take note of HISTORY
•SYMPTOMS Is there?
- Reduced Vision
- Red Eye
- Pain
- Watery Eye
- Discharge
- Photophobia
- Others

7. PHYSICAL Injury - Symptoms
•REDUCED VISION
•RED EYE
•PAIN
•WATERY EYE
•PHOTOPHOBIA

8. Physical Injury - Signs 1
Red Eye (CONJUNCTIVAL
HYPERAEMIA)

9. Physical Injury - Signs 2
Red Eye (SUBCONJUNCTIVAL
HAEMORRHAGE)

10. Physical Injury - Signs 3
Corneal Surface Irregularities /
Opacities (Abrasion / Oedema)

11. Physical Injury - Signs 4
Foreign Body

12. Physical Injury - Signs 5
HYPHAEMA
(Collection of blood in the
anterior chamber)

13. Physical Injury - Signs 6
Irregular Pupil
•“D” - shaped pupil
(IRIDODIALYSIS)
•Peaked Pupil
(IRIS PROLAPSE)

14. Physical Injury - Signs 7
Black area in white of eye
(SCLERAL PERFORATION)

15. Physical Injury - Signs 8
Eyelid and Eye Laceration

16. Physical Injury - Signs 9
PERIORBITAL HAEMATOMA

17. Physical Injury -
Orbital Floor blow-out injury

18. Left Orbital Floor Fracture -
“Tear drop sign”

19. Orbital Fracture

20. Left orbital floor fracture -
eyes looking up

21. Left orbital floor fracture -
eyes looking down

22. CHEMICAL Injury - Symptoms
•PAIN
•RED EYE
•REDUCED VISION
•WATERY EYE
•PHOTOPHOBIA

23. CHEMICAL Injury - Signs
•Skin may be affected
•Conjunctival
Hyperaemia and/or
Blanching
•Irregular Corneal
Surface / Opacity
(Corneal Epithelial
loss / oedema)

24. Chemical Injury - Management
•IRRIGATION - immediately
- tap water should be fine
- at least 10 to 15 minutes
•REFER - only after thorough irrigation
•TREATMENT - adequate irrigation
- antibiotic eyedrops
- steroidal eyedrops
- pupil dilating eyedrops
- vitamin C orally/eyedrops

25. Chemical Injury
•Remember ALKALI injury is more
devastating than that of ACID injury.
•Protein from coagulation in acid injury acts
as a buffer to neutralise the acid.
•Many alkalis and hydrofluoric acid are lipid
soluble and penetrate the tissues rapidly.
•Alcohol dissolves lipids rapidly and cause
extensive and severe epithelial cell layer
loss

26. INFECTION - Symptoms
•PAIN
•RED EYE
•DISCHARGE
•REDUCED VISION
•WATERY EYE
•PHOTOPHOBIA

27. INFECTION - Signs
•Red Eye (Hyperaemia)
•Irregular Corneal
Surface (ULCER)
•Corneal Opacity
(ABSCESS)
•HYPOPYON
(Collection of pus
behind the cornea, in
the anterior chamber)

28. Infection
•ENDOPHTHALMITIS - infection
involving the structures of the eye inside
the sclera.
•HYPOPYON is a serious sign and tend to
signify an endophthalmitis.

29. INFECTION - Management
•Urgent corneal scrappings for Gram
staining and eye swabs for culture &
sensitivities
•Treatment - fortified antibiotic/ antifungal
eyedrops (eg Gentamicin,
Cefuroxime,Ceftazidime)
- Subconjunctival antibiotics
- Intravitreal antibiotics
- IV antibiotics ?
- pupil dilating eyedrops

30. RETINAL DETACHMENT
•SYMPTOMS - Reduced central vision if
macula is affected
- Shadows or visual field
defect
- may be preceded by
1) flashes of light
2) floaters (black dots /
threads)
•PAINLESS

31. RETINAL DETACHMENT 2
•SIGNS - No external signs
- Ophthalmoscope required to see
the detachment or any preceding
retinal tear

32. Retinal Detachment 3
•More common in short-sighted individuals
•Patient may have a preceding history of eye
trauma
•TREATMENT - SURGICAL
1) Scleral Buckle
2) Gas Injection
3) VITRECTOMY
•Retinal Tears without retinal detachment
may be treated with retinal LASER.

33. CENTRAL RETINAL
ARTERIAL OCCLUSION
•SYMPTOMS - sudden loss of vision
•PAINLESS
•SIGNS - No external signs
- Ophthalmoscopy shows a
“Cherry-Red” Spot of the macula
•URGENT reduction of the intraocular
pressure eg paracentesis, iv mannitol

34. GIANT CELL (TEMPORAL)
ARTERITIS
•SYMPTOMS - Reduced vision
- Headaches / Temporal
tenderness
- general feeling of unwell
•SIGNS - Pale swollen optic disc
•Patients usually elderly
•Raised ESR
•TREATMENT - High dosage of systemic
prednisolone

35. ACUTE GLAUCOMA
•Very high intraocular pressure (rapid rise)
due to blockage of aqueous outflow

36. ACUTE GLAUCOMA -
Symptoms
•VERY PAINFUL EYE
•HEADACHES
•NAUSEA
•VOMMITING
•RED EYE
•REDUCED VISION
•WATERY EYE
•PHOTOPHOBIA

37. Note that in acute glaucoma . ...
•Patient complains of severe headaches,
nausea and vomitting (in addition to a fixed
semi-dilated pupil).
•These symptoms are similar to raised
intracranial pressure eg. intracranial bleed or
tumour.
•Check for other eye signs before ordering a
CT scan of the brain, esp. in the elderly
without a history of head injury

38. ACUTE GLAUCOMA - Signs
•Red eye
•Cornea is hazy
(OEDEMA)
•Pupil is semi-dilated
and not reacting to
light

39. ACUTE GLAUCOMA
-Management
•Refer immediately, do NOT dilate pupil
•MEDICAL - Pilocarpine eyedrops
- Beta-blocker eyedrops
eg Timolol
- IV Mannitol
- IV Acetazolamide
•SURGICAL - YAG Laser Iridotomy
- Peripheral Iridectomy
- Trabeculectomy
•PROPHYLACTIC treatment to fellow eye

40. UVEITIS
•Internal inflammation of the eye involving
the iris, ciliary body and choroid
•SYMPTOMS - PAIN
- RED EYE
- REDUCED VISION
- PHOTOPHOBIA
- DULL HEADACHE

41. UVEITIS - Signs
•Hyperaemia mainly
around the edge of
cornea (circumcorneal
injection)
•SMALL pupil
•Irregular pupil
(POSTERIOR
SYNECHIAE)

42. UVEITIS - Treatment
•Steroidal eyedrops eg dexamethasone,
prednisolone, betamethasone
•Dilating eyedrops
•Subconjunctival or peribulbar steroids
•Oral steriods

43. Uveitis - sequelae
•Glaucoma
•Cataract
•Chronic macular oedema (loss of central
vision)
•Corneal calcium deposits (Band
Keratopathy)

44. Painful CNIII Palsy
•Think of Posterior Communicating Artery
Aneurysm unless proven otherwise - the
pupil reacts poorly and may be dilated. The
patient is generally unwell. URGENT
neurosurgical referral.
•Ischaemic CNIII Palsy may be painful but
the pupil reacts well. The patient usually
appears well and has a history of diabetes
+/- hypertension.

45. PICTURE SLIDES