Ocular Urgencies and Emergencies Pam Boyce, O.D., F.A.A.O. Boyce Family Eye Care, Ltd. 528 Devon Ave. Park Ridge, IL 60068 847-518-0303
Somebody s going to lose an eye
Epidemiology 2.4 million ocular and orbital injuries in the US per year 20,000 to 68,000 are vision-threatening
Exam Ocular and medical history Visual acuity Pupil responses EOM s External exam Tonometry Visual field Fundus exam
Emergency Supplies Ph paper Eyepads/shield Surgical tape Forceps Sterile swabs Sterile irrigation solution Lid speculum medications
True Emergencies Chemical burn (alkali) Central retinal artery occlusion Sudden loss of vision Transient vision loss Penetrating injury
Urgent Situations Acute (angle closure) glaucoma Acute uveitis Hyperacute conjunctivitis Corneal abrasion Corneal foreign body Corneal ulcer Hyphema Retinal detachment Orbital cellulitis Trauma
Orbital Fractures Fracture of the orbital floor or nasal wall may force air from the sinuses into the orbit Signs include proptosis, subconjunctival air, crepitus, orbital emphysema, epistaxis, enophthalmos, and depressed nose bridge Avoid coughing and do not blow nose Treat with ice packs, nasal decongestants, and broad-spectrum antibiotics
Blow-out Fracture Due to blunt trauma to inferior rim, compressing the globe within the orbit Most common sign is restriction of vertical motility Requires x-ray or CT scan Surgical repair if diplopia persists or cosmetically unacceptable enophthalmos
LeFort Fracture Severe blunt trauma separating facial structures Usually hospitalized patients CT scan needed
Follow Up Check at one and two weeks post-trauma for diplopia and enophthalmos Education patient on signs and symptoms of orbital cellulitis and retinal detachment
Chemical Burn Time and action are critical Outcome depends on Rapidity of treatment Duration of exposure ph and concentration of solution
Acid Burn Sulfuric (battery acid), hydrofluoric, hydrochloric Usually a self-limiting burn Less damaging to cornea than alkali
Alkali Burn Lime (plaster, cement), lye (drain cleaner), ammonia (cleaning solutions) Very damaging Penetrates cell membranes
Chemical Burns Treat first Irrigate for at least 30 minutes Neutral solutions: sterile saline, H2O Take ph Continue until neutral
Penetrating Injury
Penetrating Trauma
Penetrating Trauma Plastic shield with tape until can get to emergency room. Requires surgery Antiobiotics
Anterior Uveitis Vast majority of cases are idiopathic Differentially diagnose trauma, connective tissue disorders, Sarcoid Workup several bilateral or recurrent cases
Hyperacute Conjunctivitis
Bacterial Conjunctivitis Main causes are staph, strep, neisseria, hemophilus Mucopurulent discharge No preauricular node Most are self-limiting (except neisseria) Treat with culture and broad spectrum antibiotic
Corneal Abrasion Trauma is the leading cause Males
Topical Therapy May be sufficient for small abrasions with minimal discomfort Cycloplegic Antibiotic drop or ung qid Lubrication NSAID optional Follow up 1-2 days
Corneal Laceration Small full or partial thickness lacerations may generally be treated as abrasions with patching therapy Larger wounds often require surgery
Corneal Foreign Body Get consent from patient for removal, inform of risk of scarring Evert lid to look for remaining particles Foreign body tracking Anterior chamber evaluation Seidel s sign Dilate
Irrigation Removal
Intraocular Foreign Body Take possibility into consideration with high-velocity injuries Look for: corneal laceration, iris tear, lens opacity, collapsed anterior chamber, low IOP, FB Rule out with dilation, b-scan, CT scan High risk of endophthalmitis Treatment is surgical removal
Hyphema Tear of anterior ciliary body Child vs. adult Traumatic vs. spontaneous
Hyphema Treatment Hospitalization for children and elderly Bed rest vs. limited activity Limited ocular motility Patch Cycloplege Steroids antifibrinolytic
Rebleed Usually occurs day 2-5 after initial injury Frequently worse than original hyphema
Retinal Detachment Rhegmatogenous due to a hole or break, symptoms of flashes/floaters/veil, see convex elevation of retinal next to break Exudative due to tumors, inflammatory lesions, congenital anomalies, see clear fluid elevation which shifts upon head movement
Choroidal Damage Choroid is weaker than the sclera or retina and more likely to suffer damage secondary to blunt trauma Choroidal rupture is usually from a contrecoup (indirect) injury Concentric to the disc SRNVM may be a late complication
Macula Macular holes can follow commotio retinae, choroidal ruptures, or subretinal hemorrhages Can also occur with whiplash injury May present years after trauma BIO and FANG differentiate full from partial thickness holes
Orbital Cellulitis Usually results from the spread of infection from the paranasal sinuses Additional causes are deep puncture wounds, surgical (dental), trauma, acute dacryocystitis, hordeolum, and dog or insect bites
Orbital Cellulitis Symptoms including decreased VA, pain on eye movement with decreased ocular motility, fever, and double vision differentiates orbital from preseptal cellulitis, which does not penetrate the orbital septum but involves only the eyelid and brow
Treatment Hospitalization is typically required Prognosis for full recovery is excellent when treated
Questions?