Management of specific eye problems in the ED

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Harriet Carr
5 years ago
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1 of specific eye problems in the ED CORNEAL ABRASION Causes Foreign bodies Tangential shearing injuries, e.g. poking finger into eye Exact cause of injury (Remember to exclude possibility of intraocular foreign body) - Visual Acuity - If unable, try a drop of benoxinate before proceeding - Subtarsal Check - Fluorescein instillation - glows greenish-blue if epithelium broken - Orbital X-rays (if suspecting high velocity FB) - Topical antibiotic, eg, Chloramphenicol ointment qds for 5 days - Ophthalmology review if: - Patient still symptomatic after 3 days - Large abrasion (> 1/3 corneal surface area) FOREIGN BODIES Exact cause of injury -? At work -? Wearing safety glasses -? High velocity: (power tools / hammering / chiselling) Must be particularly attentive to children who have sustained injury with toy, scissors, darts, etc to rule out penetrating injury. - Visual Acuity - if unable, try drop of benoxinate before proceeding - Suspect intraocular penetration if: - Obvious corneal/scleral laceration - Prolapse of intra-ocular contents (usually brown) - Hyphaema / Hypopyon - Alteration in pupil size/shape - Shallow anterior chamber (Refer to Penetrating Eye Injury section) - Subtarsal check

2 - Fluorescein instillation - Orbital X-rays (If Hx is of high velocity metallic/glass FB particularly without protective equipment) Any penetrating eye injury must be referred urgently to Ophthalmology. Consider analgesia, intravenous antibiotics, tetanus prophylaxis, and keep the patient supine. - Anaesthetic drops prior to FB removal, eg, benoxinate (Do not give LA to take home) - FBs can be removed if they are superficial and can be removed with a cotton bud (from the eyelid) or the bevel of a needle (from the cornea) once you have been taught how to do this. Injudicious attempts to remove deeper FBs are not advised - Topical antibiotic e.g., Chloramphenicol ointment QDS for 5 days - Review by ophthalmologist if: - Symptoms not improving over 1 2 days - Rust ring remaining - following day RADIATION BURNS Typically 6 8 hour delay before onset of symptoms Exact cause of injury, eg, welding, sun lamps - Visual Acuity - if unable; try drop of benoxinate before proceeding - Check for corneal abrasion / FB in welders - Fluorescein instillation - punctate staining of cornea might be apparent Chloramphenicol - ± Cyclopentolate 1% (Single dose) - Reassure patient that symptoms will resolve in hours. Advise re: analgesia - Advise patient to stay in darkened room for comfort NB: Do not give local anaesthetic drops to take home. CHEMICAL BURNS This is a major ophthalmic injury and is to be dealt with urgently. Alkalis are able to penetrate through cornea and anterior chamber and produce more severe burns than acids.

3 - Analgesia if required - Removal of all particulate matter - Copious irrigation with N/Saline or water for 15 min - ensure lids held wide apart and conjunctival fornices are irrigated and lids are everted. Consult senior if ph has not returned to normal after 2 litres of irrigation - ph test before and after irrigation - use Universal Litmus paper / Dipstix ph indicator - Discuss with Ophthalmology urgently (particularly if alkali or acid burns) OTHER TRAUMA PENETRATING EYE INJURY - Do not remove penetrating object - Do not press on the globe - Eye shield (not eye-pad) - Put patient in darkened room - Give appropriate analgesia and anti-emetics - Nil by mouth - Refer Ophthalmology immediately EYELID LACERATION Refer to Ophthalmology if involving lid margins or canalicular system (medial to punctum). TRAUMATIC HYPHAEMA - Refer Ophthalmology - X-ray if suspect intra-ocular foreign body. (This is penetrating injury. Blowout fracture unusual) - Also ensure that globe is intact PERIORBITAL HAEMATOMA - X-ray if suspected blowout # (check eye movements and cheek sensation) - If unable to examine due to large haematoma: - Discuss with seniors - If head injury / major trauma these problems take priority; refer when stable THE RED EYE BILATERAL RED EYES

4 - Conjunctivitis Usually sticky. May start off as unilateral red eye - Chloramphenicol for 5/7 - if not better; to go back to GP - Referral to eye casualty following day if history is chronic and not resolving on antibiotics - Advise patient about possibility of cross-infection UNILATERAL RED EYE - Particularly if associated with pain - Circumcorneal injection indicates a problem other than conjunctivitis Possible causes - Corneal ulcer - Iritis - Look for a discrete corneal opacity - Suspect particularly if contact lens wearer - Get PMH: Rheumatoid arthritis? (If YES: Refer to Ophtalmologist urgently) - Previous history - Photophobia is a good symptom to ask about if one suspects acute iritis. Pupil is also often miotic - Acute glaucoma - Hazy cornea - Dilated non-reactive pupil - Corneal abrasion / Corneal FB - Remember to exclude abrasion / FB as cause Discuss with Ophthalmology SHO ORBITAL CELLULITIS - Examination particularly: - Temperature - Extraocular eye movements - Anterior segment examination of eye

5 Proptosis is an important sign - Referral to Ophthalmologist. Give IV antibiotics as advised by Ophthalmologist SUDDEN VISUAL LOSS This usually warrants urgent referral. Discuss all cases with Emergency Department senior. RETINAL DETACHMENT Vision loss may be filmy, cloudy, irregular, or curtain like. Careful fundoscopy is mandatory. Refer to Ophthalmology. ORBITAL FRACTURES AND RETROBULBAR HAEMATOMA. These injuries can lead to loss of vision. If there is any suspicion of orbital floor fracture, then a CT is required (order an orbital CT, not just a CT head). If there is any retrobulbar haematoma, contact the OMFS registrar on call, even if the patient is due to transfer elsewhere early aspiration of the haematoma can save vision. SOURCE: - JG Adams: Emergency Medicine J Wyatt, et al, Oxford Handbook of Accident & Emergency Medicine YDH A&E Guidelines Title: Eye emergencies - management Version: 1.0 Ratification committee ED Consultants / Dr T. Bleetman, Dr C Dioszeghy Date 15 September 2010 Review Date: 15 December 2012 Reviewed next review due Dec 2014

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