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Ocular Urgencies & Emergencies: Anterior Segment -- Julie A. Tyler, OD
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Mechanical Trauma - Acute
o Lid laceration
o Conjunctival abrasions & lacerations
o Corneal abrasion
o Corneal laceration/perforation
o Corneal foreign body
o Uveitis
o Hyphema
o Orbital “Blow-out” Fracture
o Angle recession = Anterior CB tear
o Crystalline lens complications
 Subluxation/Dislocation
 Cataract
Non “treating” conditions:
o Iris sphincter tears
o Iridodialysis
o Cyclodialysis/TM tears
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Chemical Trauma
o Overview of chemical injuries
o Acidic solutions, pH<7
o Alkaline solutions, pH>7
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Triage: Now, what happened?
o Did something get into the eye?
o A chemical?  Start Lavage IMMEDIATELY
o A foreign body?
o Was it Metal-on-Metal?  DILATION required
o Was it vegetative material?  Keep secondary fungal infection risk in mind
o Is this associated with an event?
o Medico-legal: Name, Place (including address), Date, Time, and details
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Lid Laceration
o Signs/symptoms
o Goal
o Betadine scrub
o Irrigate the wound  sterile saline
o Topical antibiotic ointment
o Cover with sterile dressing if NOT surgical
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Case One: Wilma Woes…..
o A patient contacted the emergency service while the clinic was closed
following Hurricane Wilma….
o 55 year old WM
o History of trauma to the eye x 12 hours
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Conjunctival Abrasions/Lacerations
o Symptoms: Less painful than a corneal abrasion
o Signs
o Management
 Lavage with sterile saline
 Small abrasions
 Larger abrasions (or lacerations)
 Substantially large lacerations
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“Bandage” considerations…..
o Historical
o FDA approved lenses
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Corneal Abrasion
o Symptoms
o Signs
o Secondary reactions – signs & symptoms
 Anterior chamber (AC) reaction
 Secondary corneal edema
o Responds wonderfully to topical anesthetics
o Management
 Least “invasive” tool
 Cycloplege & prophylactic antibiotic
 Size considerations
 FDA Approved” Bandage Contact Lens options
 Other considerations
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Corneal Foreign Body
o Symptoms
o Signs
o Secondary anterior chamber reaction likely
o Look for signs of PENETRATING eye injury
 IF metal on metal, MUST dilate pupils to ensure no penetration into
the posterior segment
o Management - Step-by-step
 Least invasive means possible
 Follow directions for corneal abrasion
 Based on size and location of FB
 Consider referrals
 The “Rust Ring”
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Case Two: It’s been two weeks…
o 30 YO male presents during normal hours
o Complaints of mild blur & light sensitivity
o Sudden onset associated with trauma, occurred once
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Corneal Laceration/Perforation
o TRUE OCULAR EMERGENCY
o Symptoms
o Signs
o (+) Seidel’s test = see percolation of aqueous as blue stream in NaFl field
o Additional signs may be seen:
 HYPHEMA
 Anterior chamber reaction
 Relatively flattened anterior chamber
 Intraocular contents (iris) may extrude through wound
 IOP expected low
 DO NOT perform tonometry to risk further loss of AC fluid or
prolapse
o Management
o Additional concerns
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Traumatic Anterior Uveitis
o Common in patients with blunt trauma
o Common secondary concern
o Symptoms
o Signs
o Complications of traumatic uveitis
o IOP considerations
o Management
 Cycloplegia
 Corticosteroids
 Re-evaluate 12-24 hrs & taper depending on outcome
 “Differences” in opinion
 Prevent Negative Sequalae
o Upon resolution, follow-up with gonioscopy to rule-out ANGLE
RECESSION…
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Hyphema
o Symptoms
o Signs
o Often accompanied by other trauma signs
o Grade by level of blood
o Risks
 Longstanding decreased VA due to corneal blood staining
 Secondary glaucoma due to trabecular blockade
o Management
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Cycloplege
Possible topical corticosteroids if uveitis
Avoid: Blood-thinning analgesics
REST and IMMOBILIZATION
Consider “shielding” involved eye
Re-evaluate daily for first 5-7 days
Monitor IOP
“Traditional” consideration: Aminocaproic acid (Amicar)
Follow up with gonioscopy to rule-out ANGLE RECESSION
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Angle Recession
o Defined
 A traumatic cleft in the CB that occurs between the circular and
longitudinal muscle fiber bands
o Gonioscopy is necessary to identify and ascertain degree of angle recession
o Signs
o Symptoms
o Risks
 Theories
 Degree of recession  directly proportional Iris atrophy
o Management:
 Gonioscopy on all pts with hx of blunt trauma
 AFTER at least 1-month post-incident
 Perform IOP once a month for 3 months, then q 3 months for 6 months
 Long-term
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Case Report: “Picking Fruit”
o 49 year-old Hispanic male
o Complaints of a “white” pupil OD noticed ~ 1 year ago
o Was struck in the eye with tree branch
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Dislocation/Subluxation of the Crystalline Lens
o Etiology: Zonular support of the lens is damaged or lost
o Symptoms
o Signs
o Definitions: Lens position abnormalities (ectopia lentis)
 Subluxation  Partial change in position
 Dislocation  Zonules become completely detached
o Management for subluxation
 Monitor vision and lens position if stable
 Chronic, low-concentration Pilocarpine
 Clear lens extraction/exchange cataract surgery  ACIOL
o Management of dislocation
 Depends on “new” location of lens
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Crystalline Lens: Cataracts
o Any ocular trauma can result in a cataract
o Rosette pattern most common
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Orbital Blow-out Fracture
o Trauma compromising the inferior floor of the orbit
o Generally accompanied by other signs of trauma
o Signs
o Symptoms
o Management
 Careful evaluation including close evaluation on EOM testing
 Risk of infection secondary to direct sinus penetration
 Management of inflammation
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Chemical Trauma
o TRUE OCULAR EMERGENCY
o Review of Chemical Injuries
o Intact epithelium protection
o Key element is HISTORY
 What was the patient exposed to?
 What amount & over what length of time was the exposure?
 Was anything done for the patient? (eg, lavage)
o Chemical review  Acidic solutions
 pH < 7
 Bind with tissue proteins; create their own barrier
 More immediate damage but not as persistent  RED eye
 Common sources
 Sulfuric acid (H2SO4) = battery acid
 Hydrochloric acid (HCl)
 Hydrofluoric acid (HF)
 Acetic acid (CH2COOH) = vinegar
o Chemical review  Alkaline (base) solutions
 pH > 7
 Saponify fatty aspects of tissue; “melt” tissue and penetrate deeper
 Long lasting, persistent damage done WHITE EYE
 Common sources
 Ammonia (NH3) = found in household cleaners
 Lye (NaOH) = found in commercial cleaning
 Lime (CaOH2) = found in cement
 Magnesium hydroxide (MgOH2) = found in fireworks
o Signs
 Mild, Moderate, Severe
 Late complications
o Symptoms
o Diagnosis & Mx of chemical trauma
 ONLY presentation when VA not first - Lavage and then VA
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Topical anesthetic q15-20 minutes
Litmus evaluation
 If not neutral  continue irrigation
Flush, check & sweep fornices  dry materials or dead tissue
 Debridement of necrotic tissue
Topical Medications
 Cycloplegia – 0.25% Scopolomine or 1% Atropine
 Broad spectrum antibiotic
 Frequent use of non-preserved lubricants
 Questions regarding corticosteroids
 Possible bandage CL or pressure patch
Follow up and continued care
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Other “chemical” complications
o Superglue
o Nail glue
o Ear drops
o Anything that looks like an eye dropper…
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Anterior Segment “True” Ocular emergencies
o Definition: Conditions that could lead to severe vision loss, including loss of
light perception, and/or death, without immediate management - based on the
associated ocular findings
o Already covered: Corneal laceration, Chemical burns
o To cover: Acute angle closure, Orbital cellulitis
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Acute Angle Closure
o Signs
o Symptoms
o Associations: Various etiologies
 Pupil block
 Plateau iris syndrome
 Neovascular
 Mechanical
o Differential diagnosis
 Glaucomatocyclitic crisis
 Inflammatory open-angle glaucoma
 Traumatic glaucoma
 Pigmentary glaucoma
o Management
 In-office: gonio and IOP evaluation
 Topical pressure lowering meds
 Oral CAI
 Osmotic agents (mannitol or isosorbide)
 Identify underlying etiology & manage that condition (eg, lens, DR)
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Orbital Cellulitis
o Signs
o Symptoms
o Associations
 Generally direct “expansion”
 Sinus infection
 Orbital fracture
 Focal infection around the eye
 May be secondary to complications of orbital surgery or FB
o Management
 In-office
 Look for APD
 Careful evaluation of EOM
 Extensive history
o Recent infection or surgery?
o Trauma?
o Stiff neck or change in mental status?
o Diabetes or immunosuppressive disease?
 Refer
 Blood work including CBC with differential
 CT scan of the orbits and sinuses
 Possible Lumbar puncture & neuro consult
 Treatment
 Admit patient for IV antibiotics
 Prophylactic antibiotic for corneal coverage if exposure
 May take 24-36 hrs for improvement