ocular emergencies in kkm malaysia today.ppt

Ocular emergencies

1. OCULAR EMERGENCIES
OPHTHALMOLOGY TEAM, HSNI

2. Trauma

3. Trauma
Closed globe injury (not a full-thickness
wound)
Open globe injury (full-thickness wound)
•Rupture (caused by blunt trauma)
•Laceration (usually by sharp object)
Penetration (1 entry point)
Perforation (entry and exit points)
•Intraocular foreign body

4. Periorbital Haematoma
Try to open the
eyelids to assess the
eye.
If suspicious of
orbital wall fracture
or globe rupture to
proceed with
imaging.

5. Eyelid Laceration
In the presence of eyelid laceration
•assess whether lid margin is involved
•always look for other ocular injuries
Lid margin

6. Red Eye (Conjunctival
Hyperaemia)
Look hard for any ocular injury
which caused conjunctival
hyperaemia.

7. Red Eye (Subconjunctival
Haemorrhage)
In the presence
of
subconjunctival
hemorrhage,
always look for
any conjunctival
or scleral
laceration wound
and hidden
foreign bodies.

8. Corneal Surface Irregularities /
Opacities (Abrasion / Oedema)
Stain the ocular
surface with
flourescein to
identify corneal
abrasion and
always rule out
corneal laceration
which might have
Seidel positive.
Look for any
remnant foreign
body.

9. Foreign Body
Seen at
conjunctiv
a only
after
everting
the eyelid
If seen at
sclera, to
proceed with
skull x-ray
Seen at
cornea

10. Conjunctival laceration
In the presence of conjunctival laceration
wound, always look hard for sclera
laceration.

11. High velocity trauma injury
If injury was sustained due to projectiles moving
at high velocity such as:
Hammering
Welding
Metal cutting
Gun shot
Always look for foreign body on the ocular
surface and if suspicious of an entry point (eg.
conjunctival laceration wound), rule out
intraocular foreign body.
(Skull X-ray/ plain orbital CT)

12. Black area in white of eye (Scleral
Perforation)
REMINDER
•Do not attempt to

remove if
suspicious of
iris/uvea prolapsed.
•Do not pad the eye.
•Protect with an eye
shield.
•Refer Ophthal team
urgently

13. Corneal Laceration
Seidel positive
which indicates
presence of
aqueous humor
leakage from the
anterior chamber
through a full
thickness corneal
laceration wound.

14. Hyphaema (Collection of blood in
the anterior chamber)
Identify and refer all traumatic hyphema
to avoid it’s complications.

15. Irregular Pupil
IRIDODIALYSIS
PEAKED PUPIL with
iris prolapsed
•Do not attempt to
remove if suspicious
of
iris/uvea prolapsed.
•Do not pad the eye.
•Protect with an eye
shield.

16. Subluxated/ dislocated lens
Try to identify location of
natural crystalline lens or
artificial intraocular lens.
If dislocated anteriorly,
early surgery has to be
arranged.

17. Breach of anterior capsule of lens
Lens material
seen in anterior
capsule due to
traumatic
breach of
anterior lens
capsule.
Early surgery
has to be
planned.

18. Anisocoria (unequal pupil)
To rule out:
•Traumatic optic
neuropathy
•3
rd
cranial nerve
palsy
(check extraocular
muscle movement
and
ptosis)
•Traumatic Horner
syndrome (check
ptosis)

19. Traumatic Left 3
rd
Cranial Nerve
Palsy
If presence of traumatic 6
th
cranial palsy,
rule out false localising sign (space
occupying lesion) by imaging.

20. Orbital Floor blow-out
injury
Restricted vertical gaze in orbital
floor fracture.

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

22. Retrobulbar hemorrhage
If tense and proptosed
eyeball as shown, refer
Ophthalmology stat to
rule out retrobulbar
hemorrhage which may
require emergency
Lateral Canthotomy and
Cantholysis.

23. Other causes of sudden loss of
vision in trauma
Optic nerve avulsion
Vitreous hemorrhage
Rhegmatogenous retinal detachment
Commotio retinae (including Berlin’s
edema)
Choroidal rupture

24. Chemical Injury

25. Chemical Injury
Start irrigation before clerking!

26. Copious Irrigation
immediately with fluid
(normal saline or
equivalent) for 15-30
minutes or until pH is
normalized
Double-eversion of the
eyelids to remove any
retained particulate trapped
in fornices (eg. lime and
cement)

27. “White and Quiet” eye
Shown here is a severe alkali burn. Eye is “white”
due to diffuse ischemia and blanching of
conjunctival vessels.
Urgent referral must be made.

28. INFECTION

29. Corneal ulcer
Note the dense
stromal infiltration
(mid-cornea opacity)
to differentiate it from
superficial
epithelial defect
(corneal abrasion).

30. Hypopyon
Collection of pus in the anterior
chamber

31. Corneal Perforation
Site of corneal
perforation seen with
iris prolapsed
REMINDER
•Do not attempt to
remove if suspicious
of
iris prolapsed.
•Do not pad the eye.
•Protect with an eye
shield.

32. Preseptal cellulitis
Orbital cellulitis

33. To differentiate orbital cellulitis
from preseptal cellulitis
Look out for the following in orbital cellulitis:
•drop in vision
•presence of proptosis
•Injected conjunctiva +/- chemosis
•restricted extraocular muscle movement
Always look for source of infection such as
sinusitis or odontogenic abscess.

34. Acute Angle Closure

35. Acute angle closure
Symptoms
Severe headache
Nausea and vomiting
Eye pain and redness
Sudden blurring of vision
Halo
Note- may mimic increased high intracranial
pressure symptoms. Thus always check the
eye.

36. Acute Angle Closure
Signs
•Shallow anterior chamber
•Hazy cornea
•Mid-dilated pupil
•Conjunctival hyperaemia

37. How to identify shallow
angle?
If a shadow projects onto the nasal iris, the angle is
narrow, because the iris bows forward and blocks the
path of the light.
A penlight is held next to the temporal side of the eye,
with the light beam parallel to the iris, shining across the
anterior chamber.

38. WHEN TO REFER TO THE
OPHTHALMOLOGIST?

39. IMMEDIATE REFERRAL
Acute glaucoma
Chemical burn (check PH and irrigate
Corneal laceration
Globe perforation
Intra-ocular foreign body
Hypopyon (pus in anterior chamber)
Iris prolapse (cover with an eye shield)

40. IMMEDIATE REFERRAL
Orbital cellulitis
Central retinal artery occlusion (less than 8
hours onset/acute <24 course visual loss)
Giant cell arteritis with visual disturbance
Sudden unexplained visual loss of less than
12 hours
Painful eye in post operative intraocular
surgery (less than two months post op)
Acute third nerve palsy if pupil involvement
or pain

41. REFERRAL WITHIN 24
HOURS
Corneal abrasion
Corneal / conjunctival foreign body
Blunt trauma
Contact lens related problem
Corneal graft patients
Corneal ulcers or painful corneal
opacities

42. REFERRAL WITHIN 24
HOURS
Hyphema
Iritis
Lid laceration
Orbital fractures
Retinal detachment/ tear
Vitreous hemorrhage
Sudden loss of vision of more than 12
hours
Neonatal conjunctivitis
White pupil in children/lack of red reflex

43. If in any doubt,
please kindly consult the
Ophthalmology Team.

44. Thank you