Ocular Emergencies. Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital

Ocular Emergencies Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital

Ocular Anatomy

Bony Components of Orbit 1 1. Frontal bone 4 5 7 6 2. Zygomatic bone 3. Maxillary bone 4. Sphenoid bone 5. Ethmoid bone 2 3 6. Lacrimal bone 7. Palatine bone Size 30 x 40 x 45 mm

Paranasal Sinus

Orbicularis Oculi Ocular Anatomy

Ocular Anatomy

Ocular Anatomy

Ocular Anatomy

Extraocular Muscles

Optic Nerve

Venous System

Ocular Emergencies Blunt trauma Trauma Penetrating trauma Non - trauma

Acute Eye Conditions Emergency Very Urgent Urgent ( Immediately ) ( Within a few hours ) ( Within one day ) Retinal arterial Perforation Orbital cellulitis occlusion Ruptured Orbital injury Chemical burns Acute glaucoma Corneal ulcer Sudden congestion Corneal abrasion proptosis Hyphema Intraocular FB Retinal detachment Macular edema

Nontraumatic Ocular Emergencies Ocular Emergencies Ocular condiitons requiring immediate treatment Acute Angle-Closure Glaucoma Central Retinal Artery Occlusion Orbital Cellulitis Cavernous Sinus Thrombosis Endophthalmitis Retinal Detachment Toxic Causes of blindness Acute Dacryocystitis Acute Dacryoadenitis Acute Hordeolum Preseptal cellulitis Spontaneous subconjunctival hemorrhage Conjunctivitis Bacterial corneal ulcer Viral keratoconjunctivitis Acute hydrops of the cornea Hyphema Uveitis ( iritis & iridocyclitis ) Vitreous hemorrhage Retinal hemorrhage Central retinal vein occlusion Optic neuritis

Ocular burns and trauma Ocular Burn Alkali Burns Ocular Emergencies Acid Burns Thermal Burns Burns Due to Ultraviolet Radiation Mechanical Trauma to the Eye Penetrating or Perforating injuries Blunt Trauma to the Eye, Adnexa,& Orbit 1. Ecchymosis of the Eyelids 2. Lacerations of the Eyelids 3. Orbital hemorrhage 4. Fracture of the Ethmoid bone 5. Blowout Fractures of the Floor of the Orbit 6. Corneal Abrasions 7. Corneal & Conjunctival Foreign Bodies

Eye Examination Visual acuity External Eye : orbit, periorbital skin, eyelids Confrontation visual fields Ocular motility

Eye Examination Anterior Segment Conjunctiva Cornea Anterior chamber Iris Lens Pupils : RAPD

Fundus Examination A dilated pupil makes it easier to see the optic nerve, macula, and retina - 1% tropicamide ( Mydriacyl ) - 2.5% phenylephrine ( Neo-Synephrine ) PanOptic Ophthalmoscope Indirect Ophthalmoscope

Intraocular Pressure Measurement Digital palpation Schiotz tonometer

Ocular Trauma Closed Globe Open Globe Burn Laceration Rupture Laceration Contusion Penetrating Perforating

Subconjunctival Hemorrhage Causes Trauma, Hypertension Valsava pressure spikes Spontaneous No treatment Resolve within 2 weeks

Corneal Abrasion Pain, photophobia, FB sensation, tearing Conjunctival injection, swollen eyelid Epithelial staining defect with fluorescein

Corneal Abrasion : Management Searching for conjunctival foreign body Topical cycloplegia, ATB ointment Pressure patching for 24 hours Don t apply PP if there is a significant risk of infection.

Corneal Ulcer Hypopyon No patching Topical antibiotics Ophthalmologist referral Eye Shield

Conjunctival Foreign Bodies

Corneal Foreign Bodies Rust ring Corneal foreign body with rust ring

Corneal Foreign Bodies Remove the FB under the best magnification Evert the eyelid to rule out additional FB Treat resulting corneal abrasion Referral to ophthalmologist, next day Residual rust ring

Corneal Foreign Body Removal

Traumatic Hyphema Disruption of blood vessels in the iris or ciliary body Blood in anterior chamber

Traumatic Hyphema : Classification Grade Size of Hyphema 0 No layered blood circulating red blood cells only I Less than 1/3 II 1/3 to 1/2 III IV 1/2 to less than total Total

Traumatic Hyphema

Traumatic Hyphema : Management Elevate the patient s head Bed rest 1% atropine one drop 3-4 times daily 1% prednisolone acetate one drop 3-4 times daily If the globe is intact, measure IOP Reduce IOP Ophthalmology consult

Traumatic Hyphema : Management Rebleeding can occur 3 to 5 days later in 30% Uncontrolled glaucoma or blood stained cornea requires anterior chamber wash out

Lid Lacerations Sharp or blunt trauma R/O associated ocular injury Remove superficial FB Rule out deeper FB Give tetanus prophylaxis

Full Thickness Lid Lacerations Tear lid margin - Gray line - Lash line - Mucocutaneous junction

Lid Margin Repair Laceration of lower eyelid margin Post-operative result following a primary repair

Lid Lacerations Refer to ophthalmologist if there are associated ocular injuries Ruptured globe Lacrimal drainage system Levator aponeurosis Medial canthal tendon Tissue loss ( > 1/3 )

Lid Lacerations with tear canaliculi

Canalicular Repair

Tear Canthal Tendon Woman with tearing and medial canthal asymmetry after the repair of a laceration sustained during a domestic assault

Penetrating / Ruptured Globe Corneal or scleral lacerations Hypotony (not always present) Severe chemosis & hemorrhage Intraocular contents may be outside the globe Limitation of extraocular motility Shallow anterior chamber Irregular pupil

Irregular pupil

Penetrating / Ruptured Globe

Penetrating / Ruptured Globe Ruptured globe caused by golf ball

Penetrating / Ruptured Globe : Management Stop examination Shield the eye (do not patch) Give tetanus prophylaxis NPO and systemic antibiotics Do not apply eye ointment or eye drop Film orbit if IOFB can t be R/O Refer immediately to ophthalmologist

Intraocular or Intraorbital Foreign Bodies

Ocular Trauma Traumatic cataract Traumatic lens subluxation Traumatic mydriasis Traumatic lens subluxation

Chemical Ocular Injury True ocular emergency Both acid and alkali burns can be blinding - Acid burns tend to coagulate proteins, limiting the depth of penetration. - Alkali burns can rapidly penetrate the cornea, causing damage to intraocular structures.

Chemical Ocular Injury : Management Immediate copious irrigation with a minimum of 1-2 L of saline or until ph is normalized ( 7.3-7.7 ) - Instill a topical anesthetic - Use eyelid retractor - Double eversion of the eyelids

Irrigation in case of chemical injury

Chemical Ocular Injury : Management Immediate copious irrigation with a minimum of 1-2 L of saline or until ph is normalized ( 7.3-7.7 ) - Instill a topical anesthetic - Use eyelid retractor - Double eversion of the eyelids No corneal involvement - ATB + steroid eye drop Ophthalmologists Referral

Chemical Ocular Injury : Classification Grade I Grade II Grade III Grade IV

Chemical Ocular Injury : Management Preservative-free artificial tears Topical non-preserved steroid Topical cycloplegic Topical antibiotics Oral analgesics Pressure patch or bandage CL Antiglaucoma +

Bilateral Alkali Injuries Chemical Ocular Injury

Chemical Ocular Injury : Management Keratoprosthesis Corneal Transplantation

Cyanoacrylate Glue Accidental into the eye can cause the lids to adhere and adhesive clumps to form on the cornea Not permanently harmful to the eye Cyanoacrylates are used occasionally directly on the cornea to seal corneal perforations.

Cyanoacrylate Glue Moisten the glue with eye ointment, and remove as much as can be removed easily without causing damage to underlying tissue The glue will loosen and become easier to remove in a few days.

Non-traumatic Ocular Emergencies

A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting The woman suddenly experienced nausea, vomiting, and extreme pain in the left eye while in a movie theater. Her vision has worsened since that time and the eye has become very red.

A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting VA - HM Conjunctival injection Hazy cornea Shallow anterior chamber Fixed mid-dilated pupil IOP 56 mmhg Acute Angle Closure Glaucoma

Anterior Chamber Depth

Acute Angle Closure Glaucoma Reduce the intraocular pressure O.5% Timolol 1 drop 2-4 % Pilocarpine 1 drop every 15 minutes 20% Mannitol 250-500 ml IV drip Acetazolamide 500 mg oral 100% Glycerin 1 cc/kg Consult ophthalmologist

A 60-year-old woman with acute, painless loss of vision in the right eye Central Retinal Artery Occlusion Visual acuity CF LP in 90% of cases Opaque white retina and attenuated vessels

Central Retinal Artery Occlusion Treatment must be initiated immediately. Ocular massage Inhaled carbogen ( 95% O2 and 5% CO2 ) Reduced intraocular pressure Consult ophthalmologist immediately Anterior chamber paracentesis Direct infusion of t-pa or urokinase in the ophthalmic artery

A 40-year-old man with left eyelid edema and pain ( worse on eye movement )

A 40-year-old man with left eyelid edema and pain ( worse on eye movement ) Orbital Cellulitis Periorbital erythema and edema Proptosis Restricted extraocular motility Decreased visual acuity Chemosis Fever

Orbital Cellulitis Broad spectrum intravenous antibiotics CT scan orbit Ophthalmology & ENT consultation Subperiosteal abscess

Preseptal Cellulitis

Endophthalmitis

Urgent Neuro-ophthalmology

A 36-year-old-woman with subacute visual loss in right eye and pain on eye movement VA 20/200, 20/25 RAPD +ve OD VF central scotoma OD Retrobulbar optic neuritis

A 55-year-old man with HT and acute visual loss in RE VA 20/100, 20/20 RAPD +ve RE ESR 10 mm/hr Nonarteritic anterior ischemic optic neuropathy

A 73-year-old woman with acute visual loss of right eye, headache, anorexia and weight loss VA 10/200, 20/25 RAPD + ve RE Arteritic anterior ischemic optic neuropathy ESR 94 mm/hr, high level of C - reactive protein

Pathology : Giant Cell ( Temporal ) Arteritis

A 35-year-old man with left painful third nerve palsy VA 20/25, 20/30 Dilated, nonreactive pupil LE

A 35-year-old man with a suspicious of aneurysmal third nerve palsy Conventional CT scan or MRI are not the procedure of choice High false negative rate 12 40 % Magnetic resonance angiography (MRA) Computed tomography angiography (CTA) Overall sensitivity up to 97 %

A 35-year-old man with a suspicious of aneurysmal third nerve palsy

A 40-year-old woman with sudden onset of left third nerve palsy, visual loss and severe headache VA 20/30, LP +ve RAPD LE What is the diagnosis?

Pituitary Apoplexy Characterized by sudden visual loss, headache, and ophthalmoplegia secondary to rapid expansion of pituitary macroadenoma into the suprasellar space and/or cavernous sinus Commonly results from hemorrhage into a preexisting pituitary mass

A 17-year-old man with right blured vision after minor blunt trauma. VA 20/32, 20/20 + ve RAPD RE Normal fundi LE RE

A 16-year-old man with head injury and left blured vision after falls from height VA 20/30, LP + ve RAPD LE Normal fundi

Traumatic Optic Neuropathy : Classification and Mechanisms Direct injury - Penetrating injury from knife, projectile - Injury from fractured bone - Avulsion, transection Indirect injury - Contusion with transmission of force through bone - Compression secondary to orbital hemorrhage or intrasheath hemorrhage

Clinical Features of Traumatic Optic Neuropathy Most commonly unilateral May be overlooked in setting of significant globe or maxillofacial trauma Reduced visual acuity ( NLP to 20/20 ) Visual field defect : No pathognomonic defect Normal optic disc with development of optic atrophy

Medical Management Options Steroids : Controversial - Thought to limit free-radical amplification of the injury response - Dosages ( low, high, mega) - May be harmful Observation : 57% of untreated patients shown to have 3 lines or more acuity improvement

Surgical Management Options Lateral canthotomy and cantholysis for orbital hemorrhage Surgical decompression of the optic nerve within its canal There is no defined standard protocol of treatment for indirect optic nerve injury.