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OCULAR

EMERGENCIES
CME
HOSPITAL SERI MANJUNG
4 / 11 / 2015

TOPIC OVERVIEW
1.
2.
3.
4.
5.

Ocular anatomy
Classification of ocular emergencies
History taking
Eye examination
Management

OCULAR ANATOMY

OCULAR EMERGENCIES
Trauma

Penetratin
g
Blunt

Ocular
emergenci
es

Infection
NonTrauma

Foreign
body
Neuroopthalmol
ogy

HISTORY TAKING

RED EYE DANGER SIGNS


1.
2.
3.
4.
5.
6.
7.
8.

Decreased visual acuity


Pain
Ciliary flush
Pupillary asymmetry
Irregular corneal light reflex
Corneal infiltrate
Photophobia
Trauma

KEY QUESTIONS
1. Do you eye pain?
2. Do you wear contacts lens?
3. Do you have any associated
symptoms?

Decrease vision/vision loss


Photophobia
Diplopia
flashes/floaters

Acute angle
closure
glaucoma
Scleritis
Uveitis
PAINFUL

RED EYE

Keratitis
Corneal
abrasion/ulcer
Trauma/chemic
al injury
Conjunctivitis
PAINLESS

Subconjunctiva
l hmorrhage
Episcleritis

EYE EXAMINATION

SNELLEN CHART & PUPILLARY


LIGHT REFLEX

OCULAR MOTILITY

ANTERIOR CHAMBER
EXAMINATION

FUNDOSCOPY
EXAMINATION

IMMEDIATE WITHIN MINUTES

Orbital Hemorrhage

Chemical burnsCRAO

EYE TONOMETER

Endophthalmitis

VERY
URGENT
WITHIN
HOURS

Microbial
Keratitis

cavernous sinus thrombosis

IOFB
Orbital Cellulitis

Acute Glaucoma

Rupture Globe

Macula-on RD

orbital fractures

lid laceration

Hyphema

corneal abrasion

VERY
URGENT
WITHIN
1 DAY

acute ocular motility


problems
diplopia,nystagmus,lim

corneal FB

Sudden or recent loss of


vision

macula off RD

Hydrops

Abnormal
cornea

Viterous hmorhage

SUDDEN
OR
RECENT
LOSS OF
Painless
VISION

AION

CRVO

Abnormal fundus

RD

CRAO

Bullous keratopathy

SUDDEN
OR
RECENT
LOSS OF
Painfull
VISION

Keratitis

Optic neuritis

Anterior uveitis

AACG

Pain on eye movement

MANAGEMENT OF
OCULAR EMERGENCIES

1. CHEMICAL OCULAR
INJURY
Acid and alkali burns are managed in
a similar manner
Eye should be irrigate immediately at
the scene with sterile NS/Hartman
solution (2L) until the pH is normal
(pH 7.0 to 7.4)
Refer ophthal team

2. RUPTURED GLOBE
Signs suggestive of
ruptured eye globe:
Severe subconjunctival
hemorrhage
Hyphema
Teardrop-shaped pupil
abnormal anterior chamber
depth
irregular pupil
Extrusion of globe content
blindness

Refer opthal team urgent!


Eye shield should be place
ASAP, do not patch

3. LID LACERATION
Eye lid lacerations that
need opthal referral
include:
L/W 6 to 8 mm of the
medial canthus
L/W involving Lacrimal
duct or sac
L/W over Inner surface of
eye lid
L/W a/w ptosis
L/W involving the tarsal
plate or levator
palpebrae muscle

Lid laceration < 1 mm


can heal spontaneously

4. CORNEAL FOREING
BODIES
Any corneal FB deep within the
corneal stroma or in the central
visual axis should be removed by an
ophthalmologist
All patients should be referred to
ophthal team within 24 hours

5. BLOWOUT FRACTURES
Commonly involve the inferior wall
and medial wall
Result in entrapment of the inferior
rectus muscle causing diplopia on
upward gaze
Refer ophthal team

6. ACUTE ANGLE CLOSURE


GLAUCOMA
Symptoms: Eye pain + headache, cloudy vision,
colored halos around lights, vomiting
Signs:
Conjunctival injection
Corneal clouding
Increase IOP of 40 70 mmHg (normal 10 20)

Rx:
Timolol 0.5% eyedrop 1 drop stat, 2nd drop in 10 minutes
IV Acetazolamide 500mg
Pilocarpine 4% - 1 drop every 15 minutes (contraindicated in
aphakic and pseudophakic patient or in mechanical closure of
the angle)
Refer opthal team

7. CENTRAL RETINAL ARTERY


OCCLUSION (CRAO)
Symptoms:
acute painless severe
monocular loss of vision
a/w hx of amaurosis
fugax

Signs:
Complete loss of vision
Marked afferent pupillary
defect (APD)
Fundoscopy reveal cherry
red spot

Rx:
Refer ophthal team

8. CENTRAL RETINAL VEIN


OCCLUSION (CRVO)
Symptoms:
acute painless
monocular loss of vision

Signs:
Fundoscopy reveal optic
disc edema, cotton wool
spots, retinal
hemorrhage in all 4
quadrants (blood-andthunder fundus)

Rx:
Refer ophthal team

9. UVEITIS
Symptoms:
Painful red eye, worse
with eye movement
Photophobia
Blurred vision

Signs:

Conjunctival injection
Watery non-purulent D
Hypopyon
Consensual photophobia

Rx:
Refer to ophthal team stat

10.KERATITIS
Symptoms:

Photophobia
FB sensation
Tearing
Painful

Signs:
Perilimbal injection
Hypopyon

Rx:
Refer ophthal team
stat

11.SCLERITIS
Symptoms:
Severe boring eye pain, worse
with movement
Headache
Blurring of vision
Teary eye

Signs:

Impaired visual acuity


Bilateral in 50%
Tender globe
Thinning of sclera resulting in a
bluish discoloration

Rx:
Start oral NSAIDs & refer
ophthal team stat

12.OPTIC NEURITIS
Symptoms:
Unilateral LOV over
hours to days
Pain, worse with eye
movement
Visual loss commence
as pain improves

Signs:
Reduced VA
Painful RAPD

Rx:
Stat eye consultation