Download Ocular Emergencies

Ocular Emergencies
OCULAR EMERGENCIES
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Medical
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Conjunctivitis
Iritis
Periorbital Cellulitis
Glaucoma
Central Retinal
Artery Occlusion
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Surgical
• Corneal Abrasion
• Extraocular Foreign
Bodies
• Retinal Detachment
• Orbital Fracture
• Chemical Burns
• Hyphema
• Eyelid Laceration
• Globe Rupture
Assessment
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History / MOI
Time of occurrence
Treatment before arrival
Abnormal eye appearance
Visual acuity
• Snellen’s
• Visual Fields
• Finger count
Assessment
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Tearing
Itching
Discharge
Medical History
• Ocular
• Systemic
• Medication
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Always use contralateral eye for
comparison
Assessment
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Spasms of eyelid
Lesions, FB, Penetrating wounds
Pupils
EOM
Position and alignment of eye
Assessment
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Conjunctiva and sclera for color and
inflammation
Edema of lids, conjunctive, and/or
cornea
Blood
Opaque, gray-white area of cornea
Hazy cornea
Assessment
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Palpation
• Intraocular pressure: Do not do if
there is concern regarding globe
Things To Think About When
Assessing
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Younger males are at higher risk for
serious injury
School-age children are more
susceptible to conjunctivitis
Contact wearers are at greater risk for
corneal abrasions and infection
Exposure to arc welding S/S develop 48 post exposure
Things To Think About When
Assessing
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Auto mechanics and service station
attendants have potential for acid
burns to face
Injuries occurring in the garden have
increased potential for infection
Ball sports increase potential for eye
injury
Diagnostics
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Direct ophthalmoscope
Tonometry
Fluorescein staining
Slit-lamp exam
Laboratory
• Cultures
• CBC
• Coags
Diagnostics
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Radiology
• CT scan
• Soft tissue/orbit films for foreign
body
• Facial bones
• Skull films
Priorities
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ABCs
Prevent further damage
Prevent or minimize complications
Control pain
Relieve anxiety or apprehension
Education
Consultation Criteria
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Penetrating
ocular trauma
Chemical burns
of the eye
Severe lid
laceration
Glaucoma
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Central retinal
artery occlusion
Retinal
detachment
Orbital fracture
Hyphema
Periorbital
cellulitis
Age-related Pearls
Pediatric
• Delayed presentation due to children
not noticing gradual vision loss
• May need picture chart
• Infants and small children may need to
be restrained in blanket to facilitate
exam
Age-related Pearls
Geriatric
• Vision diminishes gradually until 70 y/o
and then rapidly thereafter
• Decreased near vision
• Decreased accuracy of results from
visual acuity testing
Age-related Pearls
Geriatric
• Decreased accommodation
to distances
• Decreased lacrimal
secretions
• Cataracts: at age 80 1 in 3
are affected
• More likely to experience
glaucoma, detached retina,
and retinal bleeds
Medical Ocular Emergencies
Conjunctivitis
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Inflammation of the conjunctiva
Causes:
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bacterial/viral inflammation
allergies
Chlamydia
chemical burns
FB
flash burns
Irritants
URI
Conjunctivitis
Symptoms/Assessment
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Hyperemia
Unilateral or bilateral
Slight pain
“Gritty” sensation
Discharge
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Mucopurulent
Matting of eyelids and
lashes
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Edema of eyelids
Visual acuity: Normal
Cornea: Clear
Pupil: Normal
Conjunctiva: red or
pink
Conjunctivitis
Treatment
• Antibiotics
ointment/drops
• Obtain culture, if
indicated
• Cleanse eyes gently
to remove debris
Education
• Explain contagious
nature
• Medication admin.
• Asepsis
• Wipe from nose to
outer corner of eye
• Cleanse lid with
baby shampoo
• Avoid eye makeup
• Follow-up
Iritis
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Inflammatory process that includes
the iris and sometimes the ciliary
body
Predisposing conditions: rheumatic
disease, and syphillis
Iritis
Symptoms/Assessment
• Blurring of vision
• Unilateral pain
• Edema of upper lid
• Red eye
• Photophobia
• Decreased visual
acuity
• Lacrimation
• Redness at eyelash
• Clear to hazy cornea
• Small, irregular,
sluggish reaction of
pupils
• Pain on eye
pressure
• Fluorescein stain
• Slit-lamp exam
Iritis
Treatment/Education
• Analgesics
• NSAIDs
• Cycloplegics to
paralyze ciliary
muscle and spasms
• Darkened
environment
• Rest eyes
• Warm compresses
• Shield eyes or dark
glasses
• Follow-up
Periorbital Cellulitis
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Infection of the cells around the eyes
A major ophthalmological emergency
and is potentially life threatening
May occur after trauma such as
laceration or an insect bite
Pneumococcal, staphylococcal,
streptococcal
Periorbital Cellulitis
Symptoms/Assessment
• Marked periorbital
edema and erythema
• Pain: severe that is
aggravated by
movement of eye
• Conjunctival infection
• Fever
• Visual acuity:
Decreased
• Decreases pupil
reflexes
• Paralysis of EOM
• Diagnostics
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CT scan
Culture
Gram stain
Blood culture
Periorbital Cellulitis
Treatment/Education
• Referral to
ophthalmologist
• Bedrest
• IV therapy
• IV antibiotics
• Warm compresses
Glaucoma
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Acute angle-closure glaucoma occurs
when the distance between the iris
and the cornea becomes inadequate
or is blocked completely
The aqueous fluid produce is greater
than the amount leaving through the
canal of Schlemm
Emergency Situation
May lead to irrecoverable blindness
Glaucoma
Symptoms/Assessment
• Red eye
• Severe, sudden-onset,
deep, unilateral pain
• Intense HA
• Decrease visual acuity
• Halos around lights
• N/V
• Abdominal pain
• Hazy, lusterless
cornea
• Pupils poorly
reactive or fixed
• Increased
intraocular pressure
(>20 mm Hg)
• Rocklike harness
appearance
• Diagnostic
 Tonometry
Glaucoma
Treatment/Education
• Referral to
ophthalmologist
• Analgesic
• Antiemetic
• Pilocarpine
eyedrops
• Osmotic diuretic
• Supportive and
informative
environment
Central retinal occlusion
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Blockage of the the retinal artery by
thrombus or embolus
True ocular emergency
• Prompt recognition and intervention
must be obtained within 1-2 hours of
onset
Central retinal occlusion
Symptoms/Assessment
• Sudden unilateral loss
of vision
• Painless
• History of:
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Thrombus or embolus
HTN
Diabetes
Sickle cell disease
Trauma
• Visual acuity is
limited to light
perception in
affected eye
• Pupil reaction:
dilated,
nonreactive in
affected eye
Central retinal occlusion
Treatment
• Referral to
ophthalmologist
• Digital massage of
globe by MD
• Supportive
environment
• Possible IV
therapy
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Anticoagulants
tPA
Low-molecular
weight Dextran
Admission and
possibly surgery
Surgical Ocular Emergencies
Corneal Abrasion
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Partial or complete removal of an
area of epithelium of the cornea
Most common eye injury seen in the
ER
Common causes: FB, contact lenses,
exposure to UV light
Corneal Abrasion
Symptoms/Assessment
• Mild to severe pain
• Foreign body
sensation
• Photophobia
• Normal to slightly
decreased visual
acuity
• Injected conjunctiva
• Tearing
• Abnormal Fluorescein
stain
Corneal Abrasion
Treatment
• Topical analgesic
• Topical ophthalmic
antibiotic
• Tight patch to
affected eye for 1224 hours
Education
• Follow-up care
• Proper patching
techniques
• Instillation of meds
• S/S of infection
• Use extra
precaution with
activities requiring
depth perception
Extraocular Foreign Body
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Can enter as a result from
hammering, grinding, working under
cars, or working above the head
“Something going into my eye”
Metal, sawdust, dust particles
Metal can form a rust ring on the
cornea
Extraocular Foreign Body
Symptoms/Assessment
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Pain
Foreign body sensation
Tearing
Redness
Normal to slightly
abnormal visual acuity
• Fluorscein stain
abnormal
• FB visualized
Diagnostics
• Magnifying lens
• Fluorescein stain
• Slit-lamp
Extraocular Foreign Body
Treatment
• Topical anesthetic
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Topical anesthetic
inhibit wound
healing and are
toxic to corneal
epithelium
• Gentle irrigation
with NS
• FB removal with
moist cotton swab,
needle, eye spud if
irrigation
• Patch both eyes to
reduce unsuccessful
consensual
movement
• Possible admission
Extraocular Foreign Body
Education
• Instillation of
meds
• Patching
techniques
• Follow-up care
• Provide
preventative
information
Retinal Detachment
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Separation of the retinal layers, with
accumulation of serous fluid or blood
between the sensory retina and the retinal
epithelium
Leads to decrease blood supply and
oxygen to the retina
Most common cause: degenerative
changes in the retina or vitreous body of
the elderly
Sports direct head trauma
Retinal Detachment
Symptoms/Assessment
• Gradual or sudden
deterioration of vision
unilaterally
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Cloudy, smoky vision
Flashing lights
Curtain or veil over
visual field
• No pain
Diagnostic
• Fundoscopy
• Visual acuity
• Slit-lamp exam
Retinal Detachment
Treatment
• Referral to
ophthalmologist
• Patch both eyes or
shielding to reduce
eye movement
• Bed rest, lying
quietly
• Supportive and
calm environment
• Admission or
transfer
Orbital fracture
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Fracture of the orbit without a
fracture of the orbital rim
Common cause: blunt trauma from
fist, ball, or nonpenetrating object
These fractures are associated with
entrapment and ischemia of nerves
or penetration into
a sinus
Orbital fracture
Symptoms/Assessment
• Hx of blunt trauma
• Diplopia
• Facial anesthesia
• Pain
• Sunken appearance of
the eye
• Limited vertical eye
movement
• EOM abnormal
• Crepitus
• Periorbital edema,
hematoma,
ecchymosis
• Subconjunctival
hemorrhage
• Look for other
injuries
Orbital fracture
Diagnostics
• Visual acuity
• Fundoscopy
• CT scan
• X-rays
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Orbits
Facial
Waters’
Treatment/Education
• Ophthalmological
consult
• Analgesics
• Antibiotics
• Ice pack
• Refrain from blowing
nose
• Follow-up care
• Possible admission or
surgery
Chemical Burns
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True ocular emergency
Distinction between acid and alkali
exposure must be made
Immediate irrigation
Chemical Burns
Symptoms/Assessment
• Pain
• Variable degree of
visual loss
• Chemical exposure
• Corneal whitening
Chemical Burns
Treatment
• Referral to
ophthalmology
• Irrigate with NS
for 20-30 minutes
• Administer
cycloplegic
• Analgesics
• Eye patch
• Td
Hyphema
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Blood in the anterior chamber from
the iris bleeding
Usually result of blunt trauma
Significant risk of secondary bleeding
in 3-5 days with outcomes poor
Hyphema
Symptoms/Assessm
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• Blurred vision
• Blood tinged vision
• Pain
• Visualized blood in
anterior chamber at
bottom of iris
• Assess for other
associated injuries
Hyphema
Treatment/Education
• Have patient sit
upright or bedrest
with HOB 30°
• Patch or shield both
eyes
• Diuretics to decrease
intraocular pressure
• Refrain from taking
aspirin
• Refer to
ophthalmologist
• Admission
Eyelid Laceration
Symptoms/Assessment
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MOI
Visual disturbance
Laceration
Protrusion of fat
Upper lid does not
raise
• Assess for ocular
injuries
• Bleeding
Treatment/Education
• Stop bleeding:
Avoid direct
pressure on the eye
• Surgical repair
• Topical analgesic
• Td
• Wound care
• S/S of infection
• Follow-up
Globe Rupture
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Ocular Emergency
Penetrating or perforating injury
Globe Rupture
Symptoms/Assessment
• MOI
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Blunt
Penetrating
• Sudden visual
impairment or loss
• Pain
• Asymmetry of globe
• Extrusion of aqueous
or vitreous humor
• Direct visualization
of FB
• Irregularities in
pupillary borders
• Diagnostics
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CT scan
MRI
Orbit films
Slit-lamp exam
Globe Rupture
Treatment
• Ophthalmological
referral
• Do not open eye
• Keep patient in
Semi-Fowlers
position
• Patch/shield affected
both eyes
• IV analgesics
• IV antibiotics
• Td
• Calm, supportive
environment
• Admission/Surgery
• If impaled object:
Secure it.
Do Not
Remove IT!
Questions????