Important eye emergencies in the ED

1. Eye Emergencies
Dr Dane Horsfall
Emergency Physician
Cabrini Emergency Department

2. Overview
 Eye Anatomy/Terminology
 History/Examination
 Red Eye
 Acute visual loss
 Eye Trauma

3. Anatomy

4. Anatomy

5. Terminology
 Keratitis = inflammation of
cornea
 Blepharitis = inflammation of
the eyelid
 Iritis = inflammation of Iris
 Uveitis = inflam of uvea,
(middle layer-iris, ciliary body
and choroid)
 Anterior uveitis (most
common) – inflam. iris and
ciliary body aka “Iritis”
 Intermediate uveitis –
inflam. ciliary body
 Posterior uveitis – inflam.
choroid
 Diffuse uveitis - all

6. History/Examination
 Glasses? Contact Lenses?
 Previous eye
conditions/trauma/surgery/med
s
 Visual Acuity
 Snellen chart x/y
 X is distance from chart (ie 6
metres)
 Y is smallest font size read
 Eg Normal 6/6, just top line
6/60
 Vision less than 6/60 count
no. of fingers/hand
movements/light perception
 Pin hole corrects refractory
error to 6/9 or better

7. Examination
 Visual Fields
 Evert eyelids-local
anaesthetic (Amethocaine)
aids thorough eye exam
 Eye movements “H” CN III,
IV, VI palsies, fatigability
(myasthenia)

8. Examination
 Ophthalmoscopy: dark, dioptric to zero, pt focus on
corner of room
 Pupils
 Reflex
 Symmetry
 Cornea
 Lens
 Humour
 Retina-Fundoscopy-dilate pupil-Tropicamide
 Can use cobalt blue light with fluorescein

9. Examination
 Slit Lamp-where is it?
 Lateral canthus at black line on frame
 Pt to look at examiners R ear when examining R eye
 Joystick to focus
 Cobalt blue light for fluorescein-NOT green light filter.
But Fluorescein dye appears green under blue light

10. Painful Red Eye
 Case:
 65yo F, 1/52 increasing
R unilateral eye pain
assoc n/v, Dx as
migraine
 o/e
 visual acuity reduced
 hazy cornea
 fixed mid-dilated pupil
 hard eyeball

11. Acute Angle Closure
Glaucoma
 Females in 60-70s, esp. Asians/Eskimos, +ve FHx
 defined as
 > 2 of
 ocular pain,
 nausea/vomiting,
 intermittent blurred vision with halos
 and at least 3 of:
 conjunctiva injection
 corneal epithelial oedema = hazy
 mid-dilated non-reactive pupil
 IOP >21 mmHg can be >60 mmHg
 shallower chamber in the presence of occlusion.

12. Acute Angle Closure
Glaucoma
 Aqueous humor
 produced by ciliary body
(posterior chamber)
 passes thu pupil into ant
chamber drained via trabecular
meshwork and canal of
Schlemm in the angle.
 Contact between the lens and the
iris blocks flow, pressure in
posterior chamber - iris bows
forward closing angle – reduce
drainage
 Precipitated by dilated pupil-
darkness, stress, medications
(anticholinergic, sympathomimetic)
 Chronic open angle- no pain no
attacks-slow progressive vision
loss

13. Acute Angle Closure
Glaucoma
 Intra-ocular pressure
measurement: Normal
10-20mmHg
 Goldman applanation
tonometer: attached to the slit
lamp
 Storz/Schiotz Tonometer
 Tono-Pen handheld electronic
contact tonometer ($3000)

14. Acute Angle Closure
Glaucoma
 Mx Ophthal. referral
 Acetazolamide 500mg IV
 Topical beta-blocker
 Topical steroid
 Analgesics/Anti-emetics/Supine
 Once pressure-induced ischemic paralysis of the iris
resolves around 1 hour post initial Rx then:
 Pilocarpine: a miotic (constricts pupil) – opens angle,
should be administered every 5 mins for 30 mins
 Laser peripheral iridotomy performed 24-48 hours after
IOP is controlled is definitive treatment

15. Famous Eyes
 Who’s eyes are they?

16. Painful Red Eye
 Case:
 45yo F with unilateral
red, painful eye
 PHx Crohn’s Disease
 o/e blurred vision,
perilimbal injection,
 Slit lamp
 “floaters/debris in
anterior chamber”

17. Acute Anterior Uveitis (Iritis)
 Unilateral, painful red eye, blurred vision,
photophobia, and tearing
 Peri-limbal injection, worse closer to
limbus: (conjunctivitis= worse further from
limbus)
 Visual acuity may be decreased
 Examine anterior chamber with Slit lamp
 Increase in protein content of aqueous
causes an effect known as “flare”,
looks “smokey”
 White or red blood cells may be
observed in the anterior chamber
 Severe cases - inflam. cells
accumulate as sediment in ant.
chamber = Hypopyon

18. Iritis
 Causes
 50% idiopathic
 Assoc
 CTD (ankylosing spondylitis, inflammatory bowel
disease, Reiter syndrome, psoriatic arthritis,
sarcoidosis)
 Infections: Herpes, syphilis, TB, toxoplasmosis,
histoplasmosis, CMV, Candida
 Trauma
 Mx Referral: steroids and cycloplegics,
antimicrobials.

19. Painful Red Eye
 Herpes simples –
dendritic ulcers Rx
topical Acyclovir
 Bacterial Ulcer or
Acanthamoebal ulcer:
amoeba assoc contact
lens Mx urgent Ophthal
ref. ?
admit/antimicrobials

20. Painful Red Eye - Eyelid
 Chalazion - eyelid cyst inflam. of
blocked meibomian gland -usually
painless and larger. Rx warm
compresses/antis/usually resolve
can inject steroids/surgically
remove
 Stye – infection (staph) of the
sebaceous glands at base of the
eyelashes. Rx warm compress,
pull out eyelash, antis
 Blepharitis – inflam. eyelid can be
infective. Rx warm wet compress/
antis
 Herpes Zoster – vesicular rash,
can cause infection of all parts of
eye. Nasociliary branch
involvement predicts serious
complications: ocular inflam. and
corneal denervation. Mx Opthal
ref, Acyclovir

21. Painful Red Eye
 Conjunctivitis
 Viral - recent URTI,
clear, watery discharge
 Allergic –pruritus,
clear, watery discharge
 Bacterial – pus, swab,
staph/strep/
gonococcal/chlamydia,
 Rx Chlorsig

22. Red Eye
 Scleritis:
 Inflam sclera- localized, nodular, or
diffuse
 Vision may be impaired
 Sclera thick, discoloured
 Severe pain
 Assoc with CTD (esp RA) and
Vasculitis
 Mx Analgesia, Ophthal ref steroids/
immunosuppressant
 Pterygium :
 raised yellow, fleshy lesion at
limbus, may be inflamed
 Asymptomatic or redness,
swelling, itching, irritation, blurred
vision
 r/f UV, FHx, Male
 Mx lubricant, sunglasses, refer -
surgery

23. Famous Eyes
Who’s eyes are they?

24. Case
 60yo M Sudden, painless
loss of vision L eye,
previous
partial/intermittent loss of
vision over a few days
 PHx IHD, HT, DM
 L eye light perception
only, relative afferent
pupillary defect
 Fundus: pale,
arteries/veins narrowed

25. Central Retinal Artery
Occlusion
 Embolism
 Most commonly cholesterol,
cardiac (assoc HT,DM) can be
calcific, bacterial, Giant cell
arteritis
 Amaurosis Fugax : transient
loss of vision lasting seconds
to minutes, can precede 
 Mx Urgent ophthal referral
 Decrease intra-ocular pressure
 Acetazolamide/Anterior
chamber paracentesis
 Move clot
 Pulsed ocular compression
 Anticoagulate
 Intra-arterial fibrinolysis

26. Central Retinal Vein Occlusion
 Sudden painless loss of vision
 R/F: age, HT, DM,
prothrombotic disorders
 Types: Non-ischaemic and
Ischaemic
 Signs: Decreased visual
acuity, Relative Afferent
pupillary Defect, abnormal red
reflex
 Fundus haemorrhage (“Stormy
sunset”)
 Mx Ophthal referral
 Anticoag, aspirin
 Surgery incl. Laser
photocoagulation

27. Optic Neuritis
 Vision loss (esp. colour) over hours-days,
pain with eye movements, central scotoma
 Usually unilateral, F 18-45yo may be 1st
presentation of demyelinating disease-MS
 Swollen optic disc
 May have other neurology
 Mx Ophthal referral, IV
IV steroids

28. Giant Cell Arteritis
 AKA Arteritic Ischaemic Optic
Neuropathy
 Females, 60’s
 Profound unilateral visual loss
 Check for
 Jaw claudication
 Headache
 Scalp tenderness
 Polymyalgia Rheumatica in 50%
 Fundus: disc oedema
 ESR >60mm/hr
 Rx Ophthal referral,
Prednisolone

29. Retinal Detachment
 Result of retinal hole with
seepage of fluid between
retina and choroid
 R/F age, trauma
 Signs
 flashing lights, floaters
 Vision loss may be filmy,
cloudy, irregular, or curtainlike
 Visual field defects
 Mx Ophthal ref., Repair
 Laser therapy
 Cryotherapy
 Intraocular gas (ie, pneumatic
retinopexy) tamponades retina
 Intraocular repair

30. Famous Eyes
 Who’s eyes are they?

31. Eye Trauma

32. Corneal injuries
 Corneal Abrasion
 Sensation of foreign body, light
sensitivity, tearing
 Local drops (Amethocaine 0.5%)
 Fluorescein with blue light
 Rx Chlorsig (drops/ointment)
 Corneal Flash burns
 Arc welding/UV lamp
 Red, painful, tearing
 LA, Fluorescein
 Rx Chlorsig

33. Corneal foreign body
 Dirt/glass/metal (rust ring)
 Velocity of impact
 Signs of penetration
 Removal
 Local
 25G needle, lateral
approach using slit lamp
 Dental burr for rust ring
(adherent rust ring may
loosen with Chlorsig/patch
for 24hrs as the cornea
heals, may recall pt)

34. Chemical burns
 Acids: toilet/pool cleaner,
battery fluid
 Alkalis (more harmful): lime,
mortar/plaster, drain cleaner,
oven cleaner, ammonia
 Immediate Mx: LA copious
irrigation with fluid-bag of
N/Saline + Morgan Lens until
pH 7.5, test aquity
 Degree of vascular blanching
(esp at limbus) proportional to
severity of burn
 Chlorsig, Ophthal. referral

35. Blunt Trauma - Haemorrhage
 Subconjunctival Hemorrhage
 usually benign, if spont. Check BP/
Coags
 If cant see post border ?Orbital #
 Hyphaema: blood in anterior
chamber
 If >1/3 = damage to drainage
angle, risk glaucoma
 Mx shield/patch/semi-
recumbent/rest +/-
sedation/admission
no NSAIDs, Ophthal. Ref.
 Recurrent bleeding in 10% esp
with early mobilization
 Hemorrhage vitreous or retina, can be
accompanied by a retinal detachment.
 Iris damage can result in poor pupil
reactivity = Traumatic mydriasis.
Misleading Neuro signs
 Lens can be damaged or dislocated
and a cataract may develop

36. Blunt trauma - Orbital blowout
fracture
 Usually inferior wall since weakest
 Signs:
 Diplopia/Ophthalmoplegia from
muscle entrapment. Tethering of
inferior rectus prohibits the upward
movement of the globe.
 Proptosis from swelling or
retrobulbar hemorrhage and later
Enophthalmos from loss of volume
 Infraorbital nerve entrapment- numb
cheek/upper teeth
 Epistaxis
 30% incidence of a ruptured globe in
conjunction with orbital fractures.
(Wilkins RB, Havins WE. Current treatment of blow-out
fractures. Ophthalmology. May 1982;89(5):464-6)

37. Blowout Fracture
 Mx
 Repair: Indicated if
significant diplopia or
cosmetically unacceptable
enophthalmos. Most
surgeons will wait 10 to 14
days following the trauma
to allow for resolution of the
associated edema and
hemorrhage
 Medical : if no
diplopia/enophthalmos
 o antis/no nose blowing/?
steroids

38. Ruptured Globe
 May be from blunt or
penetrating trauma
 Occurs at thinnest part:
 Limbus (Visible with slit lamp)
 Insertions of the extra-ocular
muscles (reduced eye
movements, loss red reflex
from vitreous haemorrhage)
 Around the optic nerve
 Signs:
 Pupil : peaked, teardrop-
shaped, or otherwise irregular
 Seidel’s Sign
 Enophthalmos (recession of
the globe within the orbit)
 Exophthalmos from retrobulbar
hemorrhage

40. Ruptured Globe
 Ix: CT most sensitive
 Mx : Anti-emetics/analgesics/prophylactic
antibiotics/tetanus/fast
 Urgent Ophthal. referral always requires surgical
intervention.
 ? Suxamethonium in open globe injury
controversial, weigh up risk to airway Mx and
theoretical risk of ocular extrusion and ask opthal.

41. Penetrating Eye Trauma
 Easily missed since may seal over and abnormal signs may
be subtle
 High risk with high velocity eg metal striking metal and glass
 Leave bodies insitu until surgery
 Signs:
 Distorted pupil
 Cataract
 Prolapsed black uveal tissue on the ocular surface
 Vitreous hemorrhage.
 Seidel’s Sign
 Shallow/flat anterior chamber or bubbles in anterior chamber
 Mx as for ruptured globe

42. Lid Lacerations
 Require Ophthal. ref. if:
 Torn lid margins - must
be closed accurately
 Lacrimal ducts damage
 Any suspicion of a
foreign body or
penetrating eyelid injury
 Mx refer/Tetanus/iv antis/
antiemetics/shield eye

43. Famous Eyes
 Who’s eye’s are they?

44. Golden Rules
 Always check visual acuity
 Always attempt to open eye early and
examine pupil/acuity etc in trauma
 Beware Dx unilateral conjunctivitis until more
serious disease is excluded
 Don’t D/C pt with LA drops - impedes healing,
further injury may occur to anaesthetized eye.
 Don’t start Steroid drops without
ophthalmology r/v

45. References
 Globe Rupture, J Robson, Feb 16 2007, www.emedicine.com
 Handbook of ocular disease, 2000 - 2001 Jobson Publishing,
www.revoptom.com/handbook/hbhome.htm
 P T Khaw et al, Clinical review “ABC of Eyes- Injury to the eye”
BMJ 2004;328:36-38 (3 January)
 Cameron et al, Textbook of Adult Emergency Medicine, Second Ed, Churchill
Livingston, 2004
 Eye Emergency Manual, NSW Ophthalmology Service, 2007
 Retinal Detachment, G Larkin , Apr 7, 2008 www.emedicine.com
 Acanthamoeba, N Crum-Cianflone, Jun 30 2008, www.emedicine.com
 Facial Trauma, Orbital Floor Fractures (Blowout), A Cohen, Dec 18 2006,
www.emedicine.com
 Glaucoma, Acute Angle-Closure, A Darkeh, Oct 3 2007, www.emedicine.com
 Scleritis, T Gaeta, Apr 14 2008 www.emedicine.com
 Wilkins RB, Havins WE. Current treatment of blow-out
fractures. Ophthalmology. May 1982;89(5):464-6