Lecture from penang medical college on ocular emergencies

1. OCULAR EMERGENCIES
DR. LEOW THYE YNG
BSc(Hons), MB BCh BAO (NUI),
MCOptom, MRCOphth,
FRCS(Glasg).

2. Ocular Emergencies
• Physical Injuries
• Chemical Injuries
• Infections
• Painless Sudden Loss of Vision
• Others - Acute Glaucoma
- Uveitis
- Painful CNIII Palsy

3. Ocular Emergencies
• 1) PHYSICAL Injury - Superficial
- Blunt
(Closed or Rupture)
- Penetrating
(Laceration)
- Perforating
(Entry/Exit wounds)
- Foreign Body

4. Ocular Emergencies 2
• 2) Chemical Injury
• 3) Infection - Corneal Ulcer
- Corneal Abscess
- Endophthalmitis
• 4) Painless Sudden Loss of Vision
- Retinal Detachment
- Central or Branch Retinal
Arterial Occlusion
- Giant Cell (Temporal) Arteritis

5. Ocular Emergencies 3
• 5) Acute Glaucoma
• 6) Uveitis
• 7) Painful CNIII Palsy

6. Ocular Emergencies 4
• Take note of HISTORY
• SYMPTOMS Is there?
- Reduced Vision
- Red Eye
- Pain
- Watery Eye
- Discharge
- Photophobia
- Others

7. PHYSICAL Injury - Symptoms
• REDUCED VISION
• RED EYE
• PAIN
• WATERY EYE
• PHOTOPHOBIA

8. Physical Injury - Signs 1
Red Eye (CONJUNCTIVAL
HYPERAEMIA)

9. Physical Injury - Signs 2
Red Eye (SUBCONJUNCTIVAL
HAEMORRHAGE)

10. Physical Injury - Signs 3
Corneal Surface Irregularities /
Opacities (Abrasion / Oedema)

11. Physical Injury - Signs 4
Foreign Body

12. Physical Injury - Signs 5
HYPHAEMA
(Collection of blood in the
anterior chamber)

13. Physical Injury - Signs 6
Irregular Pupil
• “D” - shaped pupil
(IRIDODIALYSIS)
• Peaked Pupil
(IRIS PROLAPSE)

14. Physical Injury - Signs 7
Black area in white of eye
(SCLERAL PERFORATION)

15. Physical Injury - Signs 8
Eyelid and Eye Laceration

16. Physical Injury - Signs 9
PERIORBITAL HAEMATOMA

17. Physical Injury -
Orbital Floor blow-out injury

18. Left Orbital Floor Fracture -
“Tear drop sign”

19. Orbital Fracture

20. Left orbital floor fracture -
eyes looking up

21. Left orbital floor fracture -
eyes looking down

22. CHEMICAL Injury - Symptoms
• PAIN
• RED EYE
• REDUCED VISION
• WATERY EYE
• PHOTOPHOBIA

23. CHEMICAL Injury - Signs
• Skin may be affected
• Conjunctival
Hyperaemia and/or
Blanching
• Irregular Corneal
Surface / Opacity
(Corneal Epithelial
loss / oedema)

24. Chemical Injury - Management
• IRRIGATION - immediately
- tap water should be fine
- at least 10 to 15 minutes
• REFER - only after thorough irrigation
• TREATMENT - adequate irrigation
- antibiotic eyedrops
- steroidal eyedrops
- pupil dilating eyedrops
- vitamin C orally/eyedrops

25. Chemical Injury
• Remember ALKALI injury is more
devastating than that of ACID injury.
• Protein from coagulation in acid injury acts
as a buffer to neutralise the acid.
• Many alkalis and hydrofluoric acid are lipid
soluble and penetrate the tissues rapidly.
• Alcohol dissolves lipids rapidly and cause
extensive and severe epithelial cell layer
loss

26. INFECTION - Symptoms
• PAIN
• RED EYE
• DISCHARGE
• REDUCED VISION
• WATERY EYE
• PHOTOPHOBIA

27. INFECTION - Signs
• Red Eye (Hyperaemia)
• Irregular Corneal
Surface (ULCER)
• Corneal Opacity
(ABSCESS)
• HYPOPYON
(Collection of pus
behind the cornea, in
the anterior chamber)

28. Infection
• ENDOPHTHALMITIS - infection
involving the structures of the eye inside
the sclera.
• HYPOPYON is a serious sign and tend to
signify an endophthalmitis.

29. INFECTION - Management
• Urgent corneal scrappings for Gram
staining and eye swabs for culture &
sensitivities
• Treatment - fortified antibiotic/ antifungal
eyedrops (eg Gentamicin,
Cefuroxime, Ceftazidime)
- Subconjunctival antibiotics
- Intravitreal antibiotics
- IV antibiotics ?
- pupil dilating eyedrops

30. RETINAL DETACHMENT
• SYMPTOMS - Reduced central vision if
macula is affected
- Shadows or visual field
defect
- may be preceded by
1) flashes of light
2) floaters (black dots /
threads)
• PAINLESS

31. RETINAL DETACHMENT 2
• SIGNS - No external signs
- Ophthalmoscope required to see
the detachment or any preceding
retinal tear

32. Retinal Detachment 3
• More common in short-sighted individuals
• Patient may have a preceding history of eye
trauma
• TREATMENT - SURGICAL
1) Scleral Buckle
2) Gas Injection
3) VITRECTOMY
• Retinal Tears without retinal detachment
may be treated with retinal LASER.

33. CENTRAL RETINAL
ARTERIAL OCCLUSION
• SYMPTOMS - sudden loss of vision
• PAINLESS
• SIGNS - No external signs
- Ophthalmoscopy shows a
“Cherry-Red” Spot of the macula
• URGENT reduction of the intraocular
pressure eg paracentesis, iv mannitol

34. GIANT CELL (TEMPORAL)
ARTERITIS
• SYMPTOMS - Reduced vision
- Headaches / Temporal
tenderness
- general feeling of unwell
• SIGNS - Pale swollen optic disc
• Patients usually elderly
• Raised ESR
• TREATMENT - High dosage of systemic
prednisolone

35. ACUTE GLAUCOMA
• Very high intraocular pressure (rapid rise)
due to blockage of aqueous outflow

36. ACUTE GLAUCOMA -
Symptoms
• VERY PAINFUL EYE
• HEADACHES
• NAUSEA
• VOMMITING
• RED EYE
• REDUCED VISION
• WATERY EYE
• PHOTOPHOBIA

37. Note that in acute glaucoma . ...
• Patient complains of severe headaches,
nausea and vomitting (in addition to a fixed
semi-dilated pupil).
• These symptoms are similar to raised
intracranial pressure eg. intracranial bleed or
tumour.
• Check for other eye signs before ordering a
CT scan of the brain, esp. in the elderly
without a history of head injury

38. ACUTE GLAUCOMA - Signs
• Red eye
• Cornea is hazy
(OEDEMA)
• Pupil is semi-dilated
and not reacting to
light

39. ACUTE GLAUCOMA
-Management
• Refer immediately, do NOT dilate pupil
• MEDICAL - Pilocarpine eyedrops
- Beta-blocker eyedrops
eg Timolol
- IV Mannitol
- IV Acetazolamide
• SURGICAL - YAG Laser Iridotomy
- Peripheral Iridectomy
- Trabeculectomy
• PROPHYLACTIC treatment to fellow eye

40. UVEITIS
• Internal inflammation of the eye involving
the iris, ciliary body and choroid
• SYMPTOMS - PAIN
- RED EYE
- REDUCED VISION
- PHOTOPHOBIA
- DULL HEADACHE

41. UVEITIS - Signs
• Hyperaemia mainly
around the edge of
cornea (circumcorneal
injection)
• SMALL pupil
• Irregular pupil
(POSTERIOR
SYNECHIAE)

42. UVEITIS - Treatment
• Steroidal eyedrops eg dexamethasone,
prednisolone, betamethasone
• Dilating eyedrops
• Subconjunctival or peribulbar steroids
• Oral steriods

43. Uveitis - sequelae
• Glaucoma
• Cataract
• Chronic macular oedema (loss of central
vision)
• Corneal calcium deposits (Band
Keratopathy)

44. Painful CNIII Palsy
• Think of Posterior Communicating Artery
Aneurysm unless proven otherwise - the
pupil reacts poorly and may be dilated. The
patient is generally unwell. URGENT
neurosurgical referral.
• Ischaemic CNIII Palsy may be painful but
the pupil reacts well. The patient usually
appears well and has a history of diabetes
+/- hypertension.

45. PICTURE SLIDES