Eye presentations to the Emergency Department

Common and Important Eye Presentations in the ED

James Richardson

The Red Eye

● One of the most

common eye presentations to ED

● Flow chart on right can help with diagnosis and urgency of referral

ConjunctivitisHxPC - red eye, sticky discharge if infective, itchy if allergic in atopic individuals

O/E - visual acuity normally maintained, pain not a major symptom, oedematous conjunctiva

Tx Infective – difficult to distinguish viral vs bacterial, topical chloramphenicol acceptable to both to stop secondary bacterial infection. Cover pseudomanas with ofloxacin in contact lens users. Allergic – sodium chromoglycate, removal of allergen. Improve 1-2 weeks

Refer if fails to respond

BacterialSticky discharge

Viral

AllergicItching is major feature, giant swollen papillae

Iritis Corneal Abrasion & UlcerHxPC – young people, painful red

eye, photophobia, reduced visual acuity, association with HLA B27 and ankolysing spondylisisO/E – reduced visual acuity, ciliary injection, pupil constricted or irregular, poorly reactive to lightTx – intense topical steroid, mydratic to dilate pupil and stop adhesion to cornea risking glaucomaRefer within 24hrs

HxPC – painful red eye, contact lens users more susceptible to infection

O/E – fluorescein shows abrasion, if opaque in white light then consider infected corneal ulcer. Remember to evert eye lid and look for FB

Tx – abrasion: chloramphenicol Infected ulcer: hourly ofloxacin day, tobramycin ointment at night

Refer if no improvement, or if ulcer >2mm for scrapings

Episcleritis Scleritis HxPC – localised patch of redness, little discomfort

O/E – visual acuity normal, localised injection of the conjunctiva and underlying episclera, no discharge

Tx – self limiting in 2 weeks, if no discomfort no treatment, if discomfort or not resolving then topical steroid

Refer – if not resolving

HxPC – rare 0.1% attendances at eye clinic, serious

O/E – Painful ocular movement. Differentiate from episcleritis with cotton bud – will move episcleral vessels, apply phenylephrine 2.5%, they blanch (will also dilate the pupil). Scleral vessels appear darker, follow a radial pattern, are immobile and do not blanch

Tx - topical and systemic steroids

Refer - urgently

Acute GlaucomaAngle between the iris and cornea narrows or closes, preventing drainage through trabecular network, increasing IOP

HxPC – very painful red eye, halos around light, patient usually over 50, N+V common, often present at night as pupil dilates

O/E – reduced visual acuity, hazy cornea with poorly visible lens, pupil fixed or semi-dilated, not responsive to light

Tx - acetazolamide IV to lower pressure. Topical pilocarpine and steroid (to reduce inflammation).

Refer – urgent referral, same day

Orbital cellulitis

HxPC – severe pain with painful eye movements, tense eyelid, pyrexia

O/E – proptosis, chemosis, diplopia, congestion of conjunctival and episcleral vessels

Tx – systemic antibiotics and analgesia

Refer same day

Sudden Painless Loss of Vision

Central retinal artery occlusion

HxPC – painless, unilateral visual loss, usually Hx HTN or IHD

O/E – relative afferant pupillary defect, cherry red spot against white ischaemic retina, arteriolar narrowing

Tx – IV acetazolamide, globe massage to lower IOP

Refer immediately

Retinal detachment

HxPC – recent Hx flashes or floaters, curtain coming down

O/E – decreased visual acuity esp. if macula involved, visual field defect greyish retina, tear

Tx – surgical, cyrotherapy or laser to repair tear, vitrectomy to relive traction

Refer same day

Injury to Eye

Penetrating ocular injury

HxPC – suspicion if high velocity fragments such as hammering stone or using power tools

O/E – pain, redness, reduced visual acuity, displacement of iris or pupil, consider x-ray or CT

Refer if suspicion, risk of ocular infection

Chemical burn

Alkali worse than acid due to rapid penetration of the eye

HxPC – exposure to eye to industrial chemicals. Most household detergents are neutral pH and less damaging

Tx – urgent copious irrigation until pH returns to normal 8

Refer immediately