Eye Emergencies

1
Eye Emergencies

• UNC Department of Emergency Medicine
• Nikki Waller
• 2009-2010

2
Infections

• Stye (External Hordeolum)
• Infected oil gland at the lid margin
• Treatment
• Warm compresses
• Erythromycin ointment for 7-10 days

3
Stye
4
Infections

• Chalazion (Internal Hordeolum)
• Infected meibomian gland (acute or chronic)
• Treatment same as stye
• Warm Compresses
• Erythromycin ointment for 7-10 days
• PLUS Doxycycline for 14-21 days in refractory
  cases
• Refer to ophthalmology for persistent cases

5
Chalazion
6
Chalazion
7
Infections

• Conjunctivitis
• Bacterial
• Eyelash matting, mucopurulent discharge,
  conjunctival inflammation (without corneal
  lesions)
• Treatment topical antibiotics
• Adults Trimethoprim-polymixin B or erythromycin
  drops
• Infants Sulfacetamide 10
• Contact lens wearers need to cover Pseudomonas
• Cipro, ofloxacin, or tobramycin topical coverage

8
Bacterial Conjunctivitis
9
Bacterial Conjunctivitis
10
Infections

• Conjunctivitis
• Bacterial
• If severe purulent discharge and hyperacute onset
  (12-24 hours), need prompt ophtho eval for
  work-up of Gonococcal conjunctivitis

11
Gonococcal Conjunctivitis
12
Infections

• Conjunctivitis
• Viral
• Monocular/Binocular watery discharge, chemosis,
  conjunctival inflammation
• Associated with
• Viral respiratory symptoms
• Palpable preauricular node
• Fluorescein stain may reveal superficial
  keratitis
• Treatment
• Cool compresses
• Naphazoline/pheniramine for conjunctival
  congestion
• Ophthalmology follow up in 7-14 days

13
Infections

• Conjunctivitis
• Viral
• Monocular/Binocular watery discharge, chemosis,
  conjunctival inflammation
• Associated with
• Viral respiratory symptoms
• Palpable preauricular node
• Fluorescein stain may reveal superficial
  keratitis
• Treatment
• Cool compresses
• Naphazoline/pheniramine for conjunctival
  congestion
• Ophthalmology follow up in 7-14 days

14
Infections

• Conjunctivitis
• Allergic
• Monocular/binocular pruritis, watery discharge,
  chemosis
• History of allergies
• No lesions seen with fluorescein staining, no
  preauricular nodes, Conjunctival papillae
• Treatment
• Eliminate inciting agent
• Cool compresses
• Artificial tears
• Naphazoline/pheniramine

15
Infections

• Conjunctivitis
• Allergic
• Monocular/binocular pruritis, watery discharge,
  chemosis
• History of allergies
• No lesions seen with fluorescein staining, no
  preauricular nodes, Conjunctival papillae
• Treatment
• Eliminate inciting agent
• Cool compresses
• Artificial tears
• Naphazoline/pheniramine

16
Infections

• Conjunctivitis
• Allergic
• Monocular/binocular pruritis, watery discharge,
  chemosis
• History of allergies
• No lesions seen with fluorescein staining, no
  preauricular nodes, Conjunctival papillae
• Treatment
• Eliminate inciting agent
• Cool compresses
• Artificial tears
• Naphazoline/pheniramine

17
Infections

• Herpes Simplex Virus
• Classic Dendritic epithelial defect
• ED care depends on the site of infection
• Eyelid and conjunctiva
• Topical antivirals (trifluorothymidine
  drops/vidarabine ointment) 5 times/day
• Topical erythromycin ointment
• Warm soaks
• Cornea
• Topical antivirals 9 times/day
• Anterior chamber
• Cycloplegic agent may be used
• First 3 days of infection Acyclovir/famcyclovir

18
Infections

• Herpes Simplex Virus
• Classic Dendritic epithelial defect
• ED care depends on the site of infection
• Eyelid and conjunctiva
• Topical antivirals (trifluorothymidine
  drops/vidarabine ointment) 5 times/day
• Topical erythromycin ointment
• Warm soaks
• Cornea
• Topical antivirals 9 times/day
• Anterior chamber
• Cycloplegic agent may be used
• First 3 days of infection Acyclovir/famcyclovir

19
Infections

• Herpes Simplex Virus
• Classic Dendritic epithelial defect
• ED care depends on the site of infection
• Eyelid and conjunctiva
• Topical antivirals (trifluorothymidine
  drops/vidarabine ointment) 5 times/day
• Topical erythromycin ointment
• Warm soaks
• Cornea
• Topical antivirals 9 times/day
• Anterior chamber
• Cycloplegic agent may be used
• First 3 days of infection Acyclovir/famcyclovir

20
Infections

• Herpes Zoster Ophthalmicus
• Shingles with trigeminal distribution, ocular
  involvement, concurrent iritis
• Pseudodentrite
• Mucous corneal plaque with epithelial erosion
• Treatment
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics for pain relief
• Ophthalmology consult mandatory

21
Infections

• Herpes Zoster Ophthalmicus
• Shingles with trigeminal distribution, ocular
  involvement, concurrent iritis
• Pseudodentrite
• Mucous corneal plaque with epithelial erosion
• Treatment
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics for pain relief
• Ophthalmology consult mandatory

22
Infections

• Herpes Zoster Ophthalmicus
• Shingles with trigeminal distribution, ocular
  involvement, concurrent iritis
• Pseudodentrite
• Mucous corneal plaque with epithelial erosion
• Treatment
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics for pain relief
• Ophthalmology consult mandatory

23
Infections

• Herpes Zoster Ophthalmicus
• Shingles with trigeminal distribution, ocular
  involvement, concurrent iritis
• Pseudodentrite
• Mucous corneal plaque with epithelial erosion
• Treatment
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics for pain relief
• Ophthalmology consult mandatory

24
Infections

• Periorbital Cellulitis (Preseptal Cellulitis)
• Warm, indurated, erythematous eyelids only
• Treatment
• Augmentin (if older than 5 years) if non-toxic
• Toxic appearing, comorbidities, younger than 5
• Hospital admission for IV Ceftriaxone/Vancomycin
• lt 5 years old Septic workup (bacteremia/meningiti
  s may be present)

25
Infections

• Periorbital Cellulitis (Preseptal Cellulitis)
• Warm, indurated, erythematous eyelids only
• Treatment
• Augmentin (if older than 5 years) if non-toxic
• Toxic appearing, comorbidities, younger than 5
• Hospital admission for IV Ceftriaxone/Vancomycin
• lt 5 years old Septic workup (bacteremia/meningiti
  s may be present)

26
Infections

• Periorbital Cellulitis (Preseptal Cellulitis)
• Warm, indurated, erythematous eyelids only
• Treatment
• Augmentin (if older than 5 years) if non-toxic
• Toxic appearing, comorbidities, younger than 5
• Hospital admission for IV Ceftriaxone/Vancomycin
• lt 5 years old Septic workup (bacteremia/meningiti
  s may be present)

27
Infections

• Orbital Cellulitis (Postseptal Cellulitis)
• Warm, indurated, erythematous eyelids only
• Fever, toxicity, proptosis, painful ocular
  motility, limited ocular excursion
• Diagnosis
• emergent orbital and sinus thin-slice CT w/o
  contrast, if negative
• CT with contrast - may reveal subperiosteal
  abscess
• Treatment
• Ophtho consult
• Hospital admission for IV Cefuroxime

28
Infections

• Orbital Cellulitis (Postseptal Cellulitis)
• Warm, indurated, erythematous eyelids only
• Fever, toxicity, proptosis, painful ocular
  motility, limited ocular excursion
• Diagnosis
• emergent orbital and sinus thin-slice CT w/o
  contrast, if negative
• CT with contrast - may reveal subperiosteal
  abscess
• Treatment
• Ophtho consult
• Hospital admission for IV Cefuroxime

29
Infections

• Corneal Ulcer
• Pain,redness, photophobia
• Etiology desiccation, trauma, direct invasion,
  contact lens use
• Slitlamp exam
• Staining corneal defect with hazy infiltrate,
• Hypopon
• Treatment
• Topical ofloxacin or cipro drops every hour
• Topical cycloplegia
• Optho eval within 24 hours

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Hypopon
31
Traumatic Eye Injuries

• Subconjunctival Hemorrhage
• Disruption of conjunctival blood vessel
• Etiology
• Trauma
• Sneezing
• Gagging
• Valsalva
• Will resolve spontaneously within 2 weeks
• If dense, circumferential bloody chemosis is
  present, must rule out globe rupture

32
Traumatic Eye Injuries

• Subconjunctival Hemorrhage
• Disruption of conjunctival blood vessel
• Etiology
• Trauma
• Sneezing
• Gagging
• Valsalva
• Will resolve spontaneously within 2 weeks
• If dense, circumferential bloody chemosis is
  present, must rule out globe rupture

33
Traumatic Eye Injuries

• Subconjunctival Hemorrhage
• Disruption of conjunctival blood vessel
• Etiology
• Trauma
• Sneezing
• Gagging
• Valsalva
• Will resolve spontaneously within 2 weeks
• If dense, circumferential bloody chemosis is
  present, must rule out globe rupture

34
Traumatic Eye Injuries

• Conjunctival Abrasion
• Superficial abrasions
• Treatment 2-3 days of erythromycin ointment
• Ocular foreign body should be excluded

35
Traumatic Eye Injuries

• Corneal Abrasion
• Tearing, photophobia, blepharospasm, severe pain
• Fluorescein dye uptake at defect site
• Rule out foreign body
• Treatment
• Cycloplegic
• Topical Tobramycin, Erythromycin, or
  Bacitracin/polymyxin drops
• Contact lens wearers Cipro, Ofloxacin, or
  Tobramycin drops
• Tetanus shot
• Ophthalmology consult within 24 hours

36
Traumatic Eye Injuries

• Corneal Abrasion
• Tearing, photophobia, blepharospasm, severe pain
• Fluorescein dye uptake at defect site
• Rule out foreign body
• Treatment
• Cycloplegic
• Topical Tobramycin, Erythromycin, or
  Bacitracin/polymyxin drops
• Contact lens wearers Cipro, Ofloxacin, or
  Tobramycin drops
• Tetanus shot
• Ophthalmology consult within 24 hours

37
Traumatic Eye Injuries

• Conjunctival Foreign Bodies
• Lid eversion
• Remove with a moistened sterile swab

38
Traumatic Eye Injuries

• Conjunctival Foreign Bodies
• Lid eversion
• Remove with a moistened sterile swab

39
Traumatic Eye Injuries

• Corneal Foreign Bodies
• May be removed with fine needle tip, eye spud, or
  eye burr after topical anesthetic applied
• Then treat as a corneal abrasion
• Deep corneal stoma FB or those in central visual
  axis require ophtho consult for removal
• Rust rings can be removed with eye burr, but not
  urgent
• Optho follow up in 24 hours for residual rust or
  deep stromal involvement

40
Traumatic Eye Injuries

• Corneal Foreign Bodies
• May be removed with fine needle tip, eye spud, or
  eye burr after topical anesthetic applied
• Then treat as a corneal abrasion
• Deep corneal stoma FB or those in central visual
  axis require ophtho consult for removal
• Rust rings can be removed with eye burr, but not
  urgent
• Optho follow up in 24 hours for residual rust or
  deep stromal involvement

41
Traumatic Eye Injuries

• Corneal Foreign Bodies
• May be removed with fine needle tip, eye spud, or
  eye burr after topical anesthetic applied
• Then treat as a corneal abrasion
• Deep corneal stoma FB or those in central visual
  axis require ophtho consult for removal
• Rust rings can be removed with eye burr, but not
  urgent
• Optho follow up in 24 hours for residual rust or
  deep stromal involvement

42
Traumatic Eye Injuries

• Corneal Foreign Bodies
• May be removed with fine needle tip, eye spud, or
  eye burr after topical anesthetic applied
• Then treat as a corneal abrasion
• Deep corneal stoma FB or those in central visual
  axis require ophtho consult for removal
• Rust rings can be removed with eye burr, but not
  urgent
• Optho follow up in 24 hours for residual rust or
  deep stromal involvement

43
Traumatic Eye Injuries

• Corneal Foreign Bodies
• May be removed with fine needle tip, eye spud, or
  eye burr after topical anesthetic applied
• Then treat as a corneal abrasion
• Deep corneal stoma FB or those in central visual
  axis require ophtho consult for removal
• Rust rings can be removed with eye burr, but not
  urgent
• Optho follow up in 24 hours for residual rust or
  deep stromal involvement

44
Traumatic Eye Injuries

• Lid Lacerations
• Must exclude damage to eye and nasolacrimal
  system
• Fluorescein staining in the tear layer that
  appear in the adjacent lac confirm nasolacrimal
  involvement
• Most require ophtho consult

45
Traumatic Eye Injuries

• Lid Lacerations
• Must exclude damage to eye and nasolacrimal
  system
• Fluorescein staining in the tear layer that
  appear in the adjacent lac confirm nasolacrimal
  involvement
• Most require ophtho consult

46
Traumatic Eye Injuries

• Lid Lacerations
• Must exclude damage to eye and nasolacrimal
  system
• Fluorescein staining in the tear layer that
  appear in the adjacent lac confirm nasolacrimal
  involvement
• Most require ophtho consult

47
Traumatic Eye Injuries
48
Traumatic Eye Injuries

• Blunt Trauma
• Immediately assess integrity of globe and visual
  acuity
• Eval depth of anterior chamber, pupil size,
  monocular blindness ? ruptured globe

49
Traumatic Eye Injuries

• Hyphema

50
Traumatic Eye Injuries

• Hyphema

51
Traumatic Eye Injuries

• Hyphema
• Blood in the anterior chamber
• Spontaneous or post-trauma
• Treatment
• Place the pt upright to allow inferior settling
  of blood
• Exclude ruptured globe
• Dilate the pupil with atropine
• Measure intraocular pressure if gt 30 mmHg apply
  topical Timolol
• Emergent Optho eval

52
Traumatic Eye Injuries

• Hyphema
• Risk for worse rebleed in the next 2-5 days is
  very high

53
Traumatic Eye Injuries

• Blowout Fractures
• Inferior and medial wall most at risk
• Evaluate for
• inferior rectus entrapment (diplopia on upward
  gaze)
• infraorbital nerve paresthesia
• subcutaneous emphysema (when blowing the nose)
• Orbital cut CT scan
• Treatment rule out ocular trauma and give oral
  Keflex
• Isolated blowout fracture ophtho eval in 3 10
  days

54
Traumatic Eye Injuries

• Blowout Fractures

55
Traumatic Eye Injuries

• Blowout Fractures

56
Traumatic Eye Injuries

• Blowout Fractures

57
Traumatic Eye Injuries

• Blowout Fractures

58
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe
• Severe subconjunctival hemorrhage
• Shallow or deep anterior chamber in one eye
• Hyphema
• Tear-drop shaped pupil

59
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe
• Severe subconjunctival hemorrhage
• Shallow or deep anterior chamber in one eye
• Hyphema
• Tear-drop shaped pupil

60
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe
• Severe subconjunctival hemorrhage
• Shallow or deep anterior chamber in one eye
• Hyphema
• Tear-drop shaped pupil
• Limited extraocular motility
• Extrusion of globe contents
• Significant reduction in visual acuity

61
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe
• Seidels test
• Fluourescein streaming

62
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe

63
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe

64
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe

65
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe

66
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe
• If a globe injury is suspected
• Dont manipulate the eye any more
• Step away from the eye
• Place the pt upright
• NPO
• Protective eye shield
• Administer IV cephazolin and antiemetic
• Tetanus

67
Traumatic Eye Injuries

• Penetrating Trauma/Ruptured Globe
• Orbital CT
• If intraocular foreign body suspected
• Call Ophtho right away

68
Traumatic Eye Injuries

• Chemical Ocular Injury
• Acid or alkali treat the same
• Immediately flush (at the scene)
• Continue to flush until pH is normal (7.0)
• Check with urine dipstick
• Recheck pH after sweeping the fornices for
  retained particles
• Measure IOP

69
Traumatic Eye Injuries

• Chemical Ocular Injury
• Treatment
• Cycloplegic
• Erythromycin ointment
• Narcotic pain meds
• Tetanus
• Immediate ophtho eval if not completely normal
  after initial measures

70
Traumatic Eye Injuries

• Crazy Glue!

71
Traumatic Eye Injuries

• Crazy Glue!
• Injury occurs only as a result of hard particles
  that form after drying
• Ophtho uses crazy glue as treatment in clinic
• Treatment
• Erythromycin ointment
• Remove pieces that are easy to remove
• Optho can remove residual glue within 48 hours

72
Traumatic Eye Injuries

• Crazy Glue!
• Mineral oil may help separate the lids
• Never use acetone or other substance that breaks
  up glue

73
Acute Vision Loss

• Acute Angle Closure Glaucoma
• Eye pain, headache, cloudy vision, colored halos
  around lights, conjunctival injection
• Fixed, mid-dilated pupil
• Increased IOP (40-70 mm Hg)
• Normal range is 10 20 mm Hg
• Nausea, vomiting

74
Acute Vision Loss

• Acute Angle Closure Glaucoma

75
Acute Vision Loss

• Acute Angle Closure Glaucoma

76
Acute Vision Loss

• Acute Angle Closure Glaucoma
• Immediate treatment
• Timolol
• Apraclonidine
• Prednisolone acetate
• If IOP gt 50 mm Hg or severe vision loss
• Acetazolamide 500mg IV
• If no decrease in IOP or vision improvement
• IV Mannitol
• Pilocarpine 1-2 in affected eye, pilocarpine
  0.5 in contralateral eye (after IOP lt 40 mm Hg)
• Immediate Ophtho consult

77
Acute Vision Loss

• Optic Neuritis
• Inflammation of the optic nerve
• Infection, demyelination, autoimmune dx
• Presentation
• Vision reduction (poor color perception)
• Pain with extraocular movement
• Afferent pupillary defect
• Swelling of the optic disc may be seen

78
Acute Vision Loss

• Optic Neuritis

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Acute Vision Loss

• Optic Neuritis
• Diagnosis
• Red Desaturation Test
• Stare at bright red object with normal eye only
• Object will appear pink or light red in affected
  eye
• Treatment
• Discuss with Ophtho

80
Acute Vision Loss

• Central Retinal Artery Occlusion
• Causes
• Thrombosis, embolus, giant cell arteritis,
  vasculitis, sickle cell disease, trauma
• Preceded by amaurosis fugax
• Painless vision loss
• May be complete or partial
• Afferent pupillary defect
• Pale fundus with narrowed arterioles and
  segmented flows (boxcars) and bright red macula
  (cherry red spot)

81
Acute Vision Loss

• Central Retinal Artery Occlusion

82
Acute Vision Loss

• Central Retinal Artery Occlusion
• Treatment
• Ocular massage!
• 15 seconds of direct pressure with sudden release
• Topical timolol or IV acetazolamide
• Emergent Optho eval

83
Acute Vision Loss

• Central Retinal Vein Occlusion
• Thrombosis diuretics and oral contraceptives
  predispose
• Painless, rapid monocular vision loss
• Fundoscopy
• Diffuse retinal hemorrhage
• Cotton wool spots
• Optic disc edema
• Blood and thunder

84
Acute Vision Loss

• Central Retinal Vein Occlusion

85
Acute Vision Loss

• Central Retinal Vein Occlusion
• Treatment
• ASA 325
• Ophtho referral

86
Acute Vision Loss

• Temporal Arteritis (Giant Cell Arteritis)

87
Acute Vision Loss

• Temporal Arteritis (Giant Cell Arteritis)
• Systemic vasculitis that can cause ischemic optic
  neuropathy
• Usually
• gt 50 years old
• Female
• Polymyalgia rheumatica

88
Acute Vision Loss

• Temporal Arteritis (Giant Cell Arteritis)
• Presentation
• Headache
• Jaw claudication
• Myalgias, fatigue
• Fever, anorexia
• Temporal artery tenderness
• TIA or stroke?
• Afferent pupillary defect

89
Acute Vision Loss

• Temporal Arteritis (Giant Cell Arteritis)
• Diagnosis
• Dont waste your time if you suspect diagnosis
• ESR, CRP
• Temporal artery biopsy (gold standard)
• Treatment
• IV steroids and Ophtho consult

90
Acute Vision Loss

• Temporal Arteritis (Giant Cell Arteritis)

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Subluxed Globe
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Subluxed Globe
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Subluxed Globe
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Subluxed Globe
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Subluxed Globe
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Subluxed Globe
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Subluxed Globe
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Subluxed Globe
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QUESTIONS
100
QUESTIONS