Ophthalmology

Ocular Emergencies

Done by: Wisudawan Abdullah

Ocular emergency

General Emergencies: trauma:

Microbial keratitis > Corneal ulcer Corneal abrasion

Uveitis Corneal & conjunctival foreign bodies

Acute angle glaucoma Hyphema

Orbital cellulitis Ruptured globe

Endophthalmitis Lid Laceration

Retinal detachment Chemical injury

❖ Hyphema:
● Hyphema isdefined as the presence of blood within
the aqueous fluid of the anterior chamber. The most
common cause of hyphema is “trauma”.
● doctors call it “8 Ball hyphema “ when it is filled with
blood . “Eight-Ball”Hyphema. This hyphema
completely fills the anterior chamber
● Can occur with blunt or penetrating injury
● Blood in the “anterior chamber”. hemosiderosis
● Can lead to high intraocular pressure.
● Detailed history to help in the treatment
 Management:
1. Bed rest to prevent re-bleeding. * “nomovement “ to prevent the
rebleeding
2. Topical steroid to reduce inflammation
3. Topical cycloplegic to cause pupil dilatation then prevent accommodation
to prevent dislodging of the clot which cause re-bleeding.
4. Antifibrinolysis agents (Tranexamic acid)
5. IOP control
6. Surgical evacuation if increase IOP, stays more than five days and not
responding to treatment.
If total wait for 3 days if not responding and pressure more than 30mmHg do
Surgical evacuation, Not total wait for 5 days if pressure less than 30 mmHg.
 ❖ Corneal Abrasion:
● Corneal abrasions result from a disruption or
loss of cells in the top layer of the cornea , called
the corneal Epithelium.
● Symptoms:
○ Foreign body sensation.
○ Severe Pain.
○ Redness.
○ Tearing .
○ Photophobia * experience of discomfort or pain
to the eyes due to light exposure
“Corneal Abrasion can lead to Corneal Ulcer if
untreated “
● Treatment:
○ Topical antibiotic. Oral analgetic
○ Cycloplegia to dilate pupil to decrease pain.
○ Pressure patch over the eye.
○ Refer to ophthalmologist.
○ Important to treat to avoid infection.
❖ ●Corneal Ulcer:
Corneal ulcer occurs secondary to lid and conjunctival inflammation but is often
due to trauma or contact lens wear
● Bacterial, viral, fungal or parasitic
● Ocular pain, redness and discharge with decrease vision and white lesion on the
cornea
● Prompt diagnosis of the etiology by doing corneal scraping (Slide, culture to
diagnose)
● Treatment with appropriate antimicrobial therapy are essential to minimize
visual loss
○ start by antibiotics, why ? because most common is bacterial, most serious
(perforation) is bacterial, it takes long time to response if u treat as fungal.
○ gram +: cefazolin (mild to moderate), vancomycin (for severe cases-stronger)
○ gram -: Ceftazidime, ofloxacin (floxa)
○ Broad spectrum ab:levofloxacin(LFX,levocin), gatifloxacin (giflox) HYPOPYON
○ we give antibiotics every hour, why ? because there is no immune
system (no blood vessels)
● Hypopyon is simply a pus collection in the anterior chamber
Contact lens wearer:

● Any redness occurring for patients who wear

contact lens should be managed with extreme caution
● Remove lens
● Rule out corneal infection
● Antibiotics for gram negative organisms
● Do not patch
● Follow up with ophthalmologist in 24 hours
 ❖ Chemical Injuries:
● A vision-threatening emergency.
● Can occur in the home, most commonly from detergents,
disinfectants, solvents, cosmetics, drain cleaners.
● Alkaline chemical injury is worse because it will cause
penetration.(liquefactive).
● Can range in severity from mild irritation to complete
destruction of the ocular surface.
● It may be aggressive and destroy eye surface “Epithelium”
causing stem cell deficiency end up with blindness.
● Destruction of optic nerve common in case of glaucoma
resulting from alkaline injury.
Management:
○ Immediate irrigation essential, with saline or Ringer’s
lactate solution, for at least 30 minutes. *immediately before take
history even* .
○ Irrigation should be continued until neutral pH is reached (i.e.,7.0) -
○ Instill topical antibiotic.
○ Instill topical anesthetic.
○ Check for and remove foreign bodies.
○ Frequent lubrications.
○ Oral pain medication.
❖ Uveitis:
● Inflammation of the uveal tissue (iris, ciliary body, or choroid) , retina, blood vessels, optic
disc, and vitreous can be involved. “the patient may has retinitis or hypopyon secondary to
uveitis “.
It could be:
1- anterior as iridoscleritis.
2- at the back as choroiditis, retinitis.
3- Panuveitis (inflammatory changes affect the anterior chamber, vitreous and retina and/or
the choroid).
● symptom and sign:
- red eye (ciliar injection)
- IOP N/ /
- Synechia
- Pupil miotic
- Pain
- Decrease vision
● Etiology:
Idiopathic 50%, Inflammatory diseases, Infectious.
● Management:
○ Identify possible cause.
○ Identify complication (glaucoma, cataract)
○ Topical steroid “first”.
○ Topical cycloplegics ."ciliary muscle is in spasm causing pain we
paralyze it temporarily to relieve pain, paralysis will cause loss of
accommodation”
○ Systemic immunosuppressive medication “according to workup,
either shift to systemic or continue topical”
■ Steroid.
■ Cyclosporine.
■ Methotrexate.
■ Azathioprine.
■ Cyclophosphamide.
○ Immunomodulating agents.
■ Infliximab (Anti TNF).
 ❖ Acute Angle Closure Glaucoma
● Result from peripheral iris blocking the outflow of fluid
➢ How the patients will present?*symptoms
● Present with pain, redness, mid-dilated pupil, decreased vision and colored
haloes around lights
● Severe headache or nausea and vomiting
● increased Intraocular pressure
● Can cause severe visual loss due to optic nerve damage
Typical history: while dimming the light.
Management :
● Medical treatment to reduce the pressure(timolol and asetazolamide) and
relieve the pain.
● peripheral laser iridotomy will be curative in most cases.
 ❖ Orbital Cellulitis:
*Orbital cellulitis is inflammation of eye tissues behind the orbital
septum. It most commonly refers to an acute spread of infection into
the eye socket from either the adjacent sinuses or through the blood.
● More serious than preseptal cellulitis because it may go to the
brain and lead to death.
● May be a consequence of preseptal cellulitis. Orbital cellulitis
Symptoms:
● Pain, Decreased vision.
● Impaired ocular motility/double vision
● Afferent pupillary defect
● Conjunctival chemosis and injection
*Chemosis of the conjunctiva is a type of eye inflammation.
It occurs when the inner lining of the eyelids swells.
● Proptosis *is a bulging of the eye anteriorly out of the orbit. Preseptal
cellulitis
Optic nerve swelling on fundus exam
‘Motility, pupil reaction, fundal exam, color vision need to be tested to
check optic nerve function. “
Management:
1. Admission.
2. Intravenous antibiotics(vancomycin)
3. Nasopharynx and blood cultures
4. Surgery may be necessary
as in case of subperiosteal abscess.so, they will drain the puss.
 ❖ Lid Laceration:
*it is not considered emergency unless it involves the canal
● Can result from sharp or blunt trauma
● Rule out associated ocular injury
● Treatment: surgery (approximate the lids and close them
following normal anatomy)
● If approximation is not following the normal anatomy:
patient will have problems (the lids will be deformed,
tearing won't be appropriate and the eye will be prone to
infections).
 ❖ Endophthalmitis (EXTREME
EMERGENCY):
*Endophthalmitis is an inflammation of the interior of the eye
● Potentially devastating complication of any intraocular
surgery
● Secondary to trauma or post-surgery (channel from outside
to inside which cause bacterial entry and it found good
environment to live in as there is no direct blood vessels in the
vitreous to provide strong immunity) – Sometimes the
destruction is due to the inflammation not the infection itself.
● Any patient in the early postoperative period (within 6
weeks of surgery) should be evaluated for pain or decreased
vision immediately.
● patient Present 2-3 days post-op with Severe redness, lid
edema and hypopyon , on exam you find vitritis.
● Intravitreal antibiotics injection plus topical antibiotics.
● Broad spectrum antibiotics or Ceftazidime and Vancomycin
● In severe infection the vitreous will be like an abscess in this case surgery is needed to drain it (Vitrectomy).
● If visualization of vitreous is not possible in case of severe infection, do B scan
● In decreased visual acuity (hand motion or less) Surgery is needed, if better give Intravitreal antibiotics only.
*Visual acuity will decide the treatment if Intravitreal antibiotics or surgery
● do surgery – if no response to antibiotics and Endophthalmitis secondary to blebitis .
*blebitis. is a presumed infection in or around a filtering bleb without vitreous involvement
 ❖ Ruptured globe:
Suspect a ruptured globe if:
● Severe blunt trauma: rapture at weak part of the eye
which is insertion of the muscles and lamina cribrosa.
● Sharp object.
● Bullous subconjunctival hemorrhage
● Uveal prolapse (Iris or ciliary body)
● Irregular pupil
● Hyphema
● Vitreous hemorrhage
● Lens opacity
● Lowered intraocular pressure
IF suspect a ruptured globe:
1. Stop examination
2. Shield the eye
3. Give tetanus prophylaxis
4. Refer immediately to ophthalmologist.
 ❖ Retinal Detachment:
 *Retinal detachment is a disorder of the eye in which the retina separates (neuronal layer from
the pigmented layer).
 Symptoms:
- Flashes, floaters, a curtain or shadow moving over the field of vision.
- Peripheral and/ or central visual loss. History of scratching the eye
- painless
 Management : Surgery
Terima kasih