Ocular Emergencies - umsa.edu.ua · PDF fileAcute Hordeolum. Preseptal cellulitis. Spontaneous subconjunctival hemorrhage. Conjunctivitis. Bacterial corneal ulcer. ... Visual acuity
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Ocular Emergencies
Pisit Preechawat, MD
Department of Ophthalmology, Ramathibodi Hospital
Ocular Anatomy
1. Frontal bone
2. Zygomatic bone
3. Maxillary bone
4. Sphenoid bone
5. Ethmoid bone
6. Lacrimal bone
7. Palatine bone
1
2 3
4 5
67
Bony Components of Orbit
Size 30 x 40 x 45 mm
Paranasal Sinus
Ocular Anatomy
Orbicularis Oculi
Ocular Anatomy
Ocular Anatomy
Extraocular Muscles
Optic Nerve
Venous System
Ocular Emergencies
Trauma
Non - trauma
Blunt trauma
Penetrating trauma
Retinal arterial Perforation Orbital cellulitisocclusion Ruptured Orbital injury
Chemical burns Acute glaucoma Corneal ulcerSudden congestion Corneal abrasion
proptosis HyphemaIntraocular FB
Retinal detachmentMacular edema
( Immediately ) ( Within a few hours ) ( Within one day )
Acute Eye Conditions
Emergency Very Urgent Urgent
Ocular condiitons requiring immediate
treatment
Acute Angle-Closure Glaucoma
Central Retinal Artery Occlusion
Orbital Cellulitis
Cavernous Sinus Thrombosis
Endophthalmitis
Retinal Detachment
Toxic Causes of blindness
Nontraumatic Ocular Emergencies
Acute Dacryocystitis
Acute Dacryoadenitis
Acute Hordeolum
Preseptal cellulitis
Spontaneous subconjunctival hemorrhage
Conjunctivitis
Bacterial corneal ulcer
Viral keratoconjunctivitis
Acute hydrops of the cornea
Hyphema
Uveitis ( iritis & iridocyclitis )
Vitreous hemorrhage
Retinal hemorrhage
Central retinal vein occlusion
Optic neuritis
Ocular Emergencies
Ocular burns and trauma
Ocular Burn
Alkali Burns
Acid Burns
Thermal Burns
Burns Due to Ultraviolet Radiation
Mechanical Trauma to the Eye
Penetrating or Perforating injuries
Blunt Trauma to the Eye, Adnexa,& Orbit
1. Ecchymosis of the Eyelids
2. Lacerations of the Eyelids
3. Orbital hemorrhage
4. Fracture of the Ethmoid bone
5. Blowout Fractures of the Floor of the Orbit
6. Corneal Abrasions
7. Corneal & Conjunctival Foreign Bodies
Ocular Emergencies
Eye Examination
Visual acuity
External Eye : orbit, periorbital skin, eyelids
Confrontation visual fields
Ocular motility
Anterior Segment
Conjunctiva
Cornea
Anterior chamber
Iris
Lens
Pupils : RAPD
Eye Examination
A dilated pupil makes it easier to see the optic nerve, macula, and retina
- 1% tropicamide ( Mydriacyl )
- 2.5% phenylephrine ( Neo-Synephrine )
PanOptic Ophthalmoscope
Indirect Ophthalmoscope
Fundus Examination
Digital palpation
Schiotz tonometer
Intraocular Pressure Measurement
Ocular Trauma
Closed Globe Open Globe
Burn
Contusion
Laceration Laceration
Penetrating Perforating
Rupture
Causes
• Trauma, Hypertension
• Valsava pressure spikes
• Spontaneous
No treatment
Resolve within 2 weeks
Subconjunctival Hemorrhage
Pain , photophobia , FB sensation, tearing
Conjunctival injection, swollen eyelid
Epithelial staining defect with fluorescein
Corneal Abrasion
Topical cycloplegia, ATB ointmentPressure patching for 24 hours
Searching for conjunctival foreign body
Don’t apply PP if there is a significant risk of infection.
Corneal Abrasion : Management
Corneal Ulcer
Hypopyon
Eye Shield
No patching
Topical antibiotics
Ophthalmologist referral
Conjunctival Foreign Bodies
Corneal foreign body with rust ring
Rust ring
Corneal Foreign Bodies
Remove the FB under the best magnification
Evert the eyelid to rule out additional FB
Treat resulting corneal abrasion
Referral to ophthalmologist, next day
Residual rust ring
Corneal Foreign Bodies
Corneal Foreign Body Removal
Disruption of blood vessels in the iris or ciliary body
Blood in anterior chamber
Traumatic Hyphema
Grade Size of Hyphema
0 No layered bloodcirculating red blood cells only
I Less than 1/3
II 1/3 to 1/2
III 1/2 to less than total
IV Total
Traumatic Hyphema : Classification
Traumatic Hyphema
Elevate the patient’s head
Bed rest
1% atropine one drop 3-4 times daily
1% prednisolone acetate one drop 3-4 times daily
If the globe is intact, measure IOP
Reduce IOP
Ophthalmology consult
Traumatic Hyphema : Management
Rebleeding can occur 3 to 5 days later in 30%
Uncontrolled glaucoma or blood stained cornea
requires anterior chamber “wash out”
Traumatic Hyphema : Management
Sharp or blunt trauma
R/O associated ocular injury
Remove superficial FB
Rule out deeper FB
Give tetanus prophylaxis
Lid Lacerations
Tear lid margin
Full Thickness Lid Lacerations
- Gray line
- Lash line
- Mucocutaneous junction
Laceration of lower eyelid margin Post-operative result following a primary repair
Lid Margin Repair
Refer to ophthalmologist if there are associated ocular injuries
Lid Lacerations
Ruptured globe
Lacrimal drainage system
Levator aponeurosis
Medial canthal tendon
Tissue loss ( > 1/3 )
Lid Lacerations with tear canaliculi
Canalicular Repair
Tear Canthal Tendon
Woman with tearing and medial canthal asymmetry after the repair of a laceration sustained during a domestic assault
Penetrating / Ruptured Globe
Corneal or scleral lacerations
Hypotony (not always present)
Severe chemosis & hemorrhage
Intraocular contents may be outside the globe
Limitation of extraocular motility
Shallow anterior chamber
Irregular pupil
Irregular pupil
Penetrating / Ruptured Globe
Ruptured globe caused by golf ball
Penetrating / Ruptured Globe
Penetrating / Ruptured Globe : Management
Stop examination
Shield the eye (do not patch)
Give tetanus prophylaxis
NPO and systemic antibiotics
Do not apply eye ointment or eye drop
Film orbit if IOFB can’t be R/O
Refer immediately to ophthalmologist
Intraocular or Intraorbital Foreign Bodies
Ocular Trauma
Traumatic cataract
Traumatic mydriasis Traumatic lens subluxation
Traumatic lens subluxation
True ocular emergency
Both acid and alkali burns can be blinding
- Acid burns tend to coagulate proteins, limiting
the depth of penetration.
- Alkali burns can rapidly penetrate the cornea,
causing damage to intraocular structures.
Chemical Ocular Injury
Immediate copious irrigation with a minimum of
1-2 L of saline or until pH is normalized ( 7.3-7.7 )
- Instill a topical anesthetic
- Use eyelid retractor
- Double eversion of the eyelids
Chemical Ocular Injury : Management
Irrigation in case of chemical injury
Immediate copious irrigation with a minimum of
1-2 L of saline or until pH is normalized ( 7.3-7.7 )
- Instill a topical anesthetic
- Use eyelid retractor
- Double eversion of the eyelids
Chemical Ocular Injury : Management
Ophthalmologists Referral
No corneal involvement
- ATB + steroid eye drop
Chemical Ocular Injury : Classification
Grade I Grade II
Grade III Grade IV
Chemical Ocular Injury : Management
Preservative-free artificial tears
Topical non-preserved steroid
Topical cycloplegic
Topical antibiotics
Oral analgesics
Pressure patch or bandage CL
Antiglaucoma +
Bilateral Alkali Injuries
Chemical Ocular Injury
Chemical Ocular Injury : Management
Corneal Transplantation
Keratoprosthesis
Accidental into the eye can cause the lids to
adhere and adhesive clumps to form on the cornea
Not permanently harmful to the eye
Cyanoacrylates are used occasionally directly on the
cornea to seal corneal perforations.
Cyanoacrylate Glue
Moisten the glue with eye ointment, and remove
as much as can be removed easily without causing
damage to underlying tissue
The glue will loosen and become easier to remove
in a few days.
Cyanoacrylate Glue
Non-traumatic Ocular Emergencies
The woman suddenly experienced nausea, vomiting, and extreme pain in the left eye while in a movie theater. Her vision has worsened since that time and the eye has become very red.
A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting
VA - HM
Conjunctival injection
Hazy cornea
Shallow anterior chamber
Fixed mid-dilated pupil
A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting
Acute Angle Closure Glaucoma
IOP 56 mmHg
Anterior Chamber Depth
Reduce the intraocular pressure
O.5% Timolol 1 drop
2-4 % Pilocarpine 1 drop every 15 minutes
20% Mannitol 250-500 ml IV drip
Acetazolamide 500 mg oral
100% Glycerin 1 cc/kg
Consult ophthalmologist
Acute Angle Closure Glaucoma
A 60-year-old woman with acute, painless loss of vision in the right eye
Visual acuity CF – LP in 90% of cases
Opaque white retina and attenuated vessels
Central Retinal Artery Occlusion
Treatment must be initiated immediately.
Ocular massage
Inhaled carbogen ( 95% O2 and 5% CO2 )
Reduced intraocular pressure
Central Retinal Artery Occlusion
Consult ophthalmologist immediately
Anterior chamber paracentesis
Direct infusion of t-PA or urokinase in the
ophthalmic artery
A 40-year-old man with left eyelid edema and pain
( worse on eye movement )
A 40-year-old man with left eyelid edema and pain
( worse on eye movement )
Periorbital erythema and edema
Proptosis
Restricted extraocular motility
Decreased visual acuity
Chemosis
Fever
Orbital Cellulitis
Broad spectrum intravenous antibiotics
CT scan orbit
Ophthalmology & ENT consultation
Orbital Cellulitis
Subperiosteal abscess
Preseptal Cellulitis
Endophthalmitis
Urgent Neuro-ophthalmology
A 36-year-old-woman with subacute visual loss in right eye and pain on eye movement
VA 20/200, 20/25 RAPD +ve OD
VF central scotoma OD
Retrobulbar optic neuritis
A 55-year-old man with HT and acute visual loss in RE
VA 20/100, 20/20 RAPD +ve RE
Nonarteritic anterior ischemic optic neuropathy
ESR 10 mm/hr
A 73-year-old woman with acute visual loss of right eye, headache, anorexia and weight loss
VA 10/200, 20/25 RAPD + ve RE
ESR 94 mm/hr, high level of C - reactive protein
Arteritic anterior ischemic optic neuropathy
Pathology : Giant Cell ( Temporal ) Arteritis
A 35-year-old man with left painful third nerve palsy
VA 20/25, 20/30
Dilated, nonreactive pupil LE
A 35-year-old man with a suspicious of aneurysmal third nerve palsy
Conventional CT scan or MRI are not the procedure of choice
High false negative rate 12 – 40 %
Magnetic resonance angiography (MRA)
Computed tomography angiography (CTA)
Overall sensitivity up to 97 %
A 35-year-old man with a suspicious of aneurysmal third nerve palsy
A 40-year-old woman with sudden onset of left third nerve palsy, visual loss and severe headache
What is the diagnosis?
VA 20/30, LP +ve RAPD LE
Pituitary Apoplexy
Characterized by sudden visual loss, headache, and ophthalmoplegia secondary to rapid expansion of pituitary macroadenoma into the suprasellar space and/or cavernous sinus
Commonly results from hemorrhage into a pre-existing pituitary mass
A 17-year-old man with right blured vision after minor blunt trauma.
VA 20/32, 20/20 + ve RAPD RE
Normal fundi
RELE
A 16-year-old man with head injury and left blured vision after falls from height
VA 20/30, LP + ve RAPD LE
Normal fundi
Traumatic Optic Neuropathy :
Classification and Mechanisms
Direct injury
- Penetrating injury from knife, projectile
- Injury from fractured bone
- Avulsion, transection
Indirect injury
- Contusion with transmission of force through bone
- Compression secondary to orbital hemorrhage or
intrasheath hemorrhage
Clinical Features of Traumatic Optic Neuropathy
Most commonly unilateral
May be overlooked in setting of significant
globe or maxillofacial trauma
Reduced visual acuity ( NLP to 20/20 )
Visual field defect : No pathognomonic defect
Normal optic disc with development of optic atrophy
Medical Management Options
Steroids : Controversial
- Thought to limit free-radical amplification
of the injury response
- Dosages ( low, high, mega)
- May be harmful
Observation : 57% of untreated patients shown to have 3 lines or more acuity improvement
Surgical Management Options
Lateral canthotomy and cantholysis for orbital hemorrhage
Surgical decompression of the optic nerve within its canal
There is no defined standard protocol of
treatment for indirect optic nerve injury .
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