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Ocular Emergencies

Pisit Preechawat, MD
Department of Ophthalmology, Ramathibodi Hospital
Ocular Anatomy
Bony Components of Orbit

1. Frontal bone
2. Zygomatic bone
3. Maxillary bone
4 5 4. Sphenoid bone
6 5. Ethmoid bone
6. Lacrimal bone
2 3
7. Palatine bone

Size 30 x 40 x 45 mm
Paranasal Sinus
Ocular Anatomy

Orbicularis Oculi
Ocular Anatomy
Ocular Anatomy
Ocular Anatomy
Extraocular Muscles
Optic Nerve
Venous System
Ocular Emergencies

Blunt trauma

Penetrating trauma

Non - trauma
Acute Eye Conditions

Emergency Very Urgent Urgent

( Immediately ) ( Within a few hours ) ( Within one day )

Retinal arterial Perforation Orbital cellulitis

occlusion Ruptured Orbital injury
Chemical burns Acute glaucoma Corneal ulcer
Sudden congestion Corneal abrasion
proptosis Hyphema
Intraocular FB
Retinal detachment
Macular edema
Nontraumatic Ocular Emergencies
Acute Dacryocystitis

Ocular Emergencies Acute Dacryoadenitis

Acute Hordeolum
Preseptal cellulitis
Spontaneous subconjunctival hemorrhage
Ocular condiitons requiring immediate Bacterial corneal ulcer
treatment Viral keratoconjunctivitis
Acute Angle-Closure Glaucoma Acute hydrops of the cornea
Central Retinal Artery Occlusion Hyphema
Orbital Cellulitis Uveitis ( iritis & iridocyclitis )
Cavernous Sinus Thrombosis Vitreous hemorrhage
Endophthalmitis Retinal hemorrhage
Retinal Detachment Central retinal vein occlusion
Toxic Causes of blindness Optic neuritis
Ocular burns and trauma
Ocular Burn
Alkali Burns
Acid Burns
Ocular Emergencies Thermal Burns
Burns Due to Ultraviolet Radiation
Mechanical Trauma to the Eye
Penetrating or Perforating injuries
Blunt Trauma to the Eye, Adnexa,& Orbit
1. Ecchymosis of the Eyelids
2. Lacerations of the Eyelids
3. Orbital hemorrhage
4. Fracture of the Ethmoid bone
5. Blowout Fractures of the Floor of the Orbit
6. Corneal Abrasions
7. Corneal & Conjunctival Foreign Bodies
Eye Examination

Visual acuity

External Eye : orbit, periorbital skin, eyelids

Confrontation visual fields

Ocular motility
Eye Examination

Anterior Segment
Anterior chamber
Pupils : RAPD
Fundus Examination

A dilated pupil makes it easier to see the optic

nerve, macula, and retina

- 1% tropicamide ( Mydriacyl )
- 2.5% phenylephrine ( Neo-Synephrine )

Intraocular Pressure Measurement

Digital palpation
Schiotz tonometer
Ocular Trauma

Closed Globe Open Globe

Burn Laceration Rupture Laceration


Penetrating Perforating
Subconjunctival Hemorrhage

Trauma, Hypertension
Valsava pressure spikes

No treatment
Resolve within 2 weeks
Corneal Abrasion

Pain , photophobia ,
FB sensation, tearing
Conjunctival injection,
swollen eyelid

Epithelial staining defect with fluorescein

Corneal Abrasion : Management

Searching for conjunctival foreign body

Topical cycloplegia, ATB ointment

Pressure patching for 24 hours

Dont apply PP if there is a

significant risk of infection.
Corneal Ulcer


No patching
Topical antibiotics
Ophthalmologist referral
Eye Shield
Conjunctival Foreign Bodies
Corneal Foreign Bodies

Rust ring
Corneal foreign body with rust ring
Corneal Foreign Bodies

Remove the FB under the best magnification

Evert the eyelid to rule out additional FB
Treat resulting corneal abrasion
Referral to ophthalmologist, next day

Residual rust ring

Corneal Foreign Body Removal
Traumatic Hyphema

Disruption of blood vessels in the iris or ciliary body

Blood in anterior chamber
Traumatic Hyphema : Classification

Grade Size of Hyphema

0 No layered blood
circulating red blood cells only

I Less than 1/3

II 1/3 to 1/2

III 1/2 to less than total

IV Total
Traumatic Hyphema
Traumatic Hyphema : Management

Elevate the patients head

Bed rest
1% atropine one drop 3-4 times daily
1% prednisolone acetate one drop 3-4 times daily
If the globe is intact, measure IOP
Reduce IOP
Ophthalmology consult
Traumatic Hyphema : Management

Rebleeding can occur 3 to 5 days later in 30%

Uncontrolled glaucoma or blood stained cornea
requires anterior chamber wash out
Lid Lacerations

Sharp or blunt trauma

R/O associated ocular injury
Remove superficial FB
Rule out deeper FB
Give tetanus prophylaxis
Full Thickness Lid Lacerations

Tear lid margin

- Gray line
- Lash line
- Mucocutaneous junction
Lid Margin Repair

Post-operative result following a

Laceration of lower eyelid margin primary repair
Lid Lacerations

Refer to ophthalmologist if there are

associated ocular injuries

Ruptured globe
Lacrimal drainage system
Levator aponeurosis
Medial canthal tendon
Tissue loss ( > 1/3 )
Lid Lacerations with tear canaliculi
Canalicular Repair
Tear Canthal Tendon

Woman with tearing and medial canthal

asymmetry after the repair of a laceration
sustained during a domestic assault
Penetrating / Ruptured Globe

Corneal or scleral lacerations

Hypotony (not always present)
Severe chemosis & hemorrhage
Intraocular contents may be outside the globe
Limitation of extraocular motility
Shallow anterior chamber
Irregular pupil
Irregular pupil
Penetrating / Ruptured Globe
Penetrating / Ruptured Globe

Ruptured globe caused by golf ball

Penetrating / Ruptured Globe : Management

Stop examination
Shield the eye (do not patch)
Give tetanus prophylaxis
NPO and systemic antibiotics
Do not apply eye ointment or eye drop
Film orbit if IOFB cant be R/O
Refer immediately to ophthalmologist
Intraocular or Intraorbital Foreign Bodies
Ocular Trauma

Traumatic cataract Traumatic lens subluxation

Traumatic mydriasis Traumatic lens subluxation

Chemical Ocular Injury

True ocular emergency

Both acid and alkali burns can be blinding
- Acid burns tend to coagulate proteins, limiting
the depth of penetration.
- Alkali burns can rapidly penetrate the cornea,
causing damage to intraocular structures.
Chemical Ocular Injury : Management

Immediate copious irrigation with a minimum of

1-2 L of saline or until pH is normalized ( 7.3-7.7 )
- Instill a topical anesthetic
- Use eyelid retractor
- Double eversion of the eyelids
Irrigation in case of chemical injury
Chemical Ocular Injury : Management

Immediate copious irrigation with a minimum of

1-2 L of saline or until pH is normalized ( 7.3-7.7 )
- Instill a topical anesthetic
- Use eyelid retractor
- Double eversion of the eyelids

No corneal involvement
- ATB + steroid eye drop

Ophthalmologists Referral
Chemical Ocular Injury : Classification

Grade I Grade II

Grade III Grade IV

Chemical Ocular Injury : Management

Preservative-free artificial tears

Topical non-preserved steroid
Topical cycloplegic
Topical antibiotics
Oral analgesics
Pressure patch or bandage CL
Antiglaucoma +
Chemical Ocular Injury

Bilateral Alkali Injuries

Chemical Ocular Injury : Management


Corneal Transplantation
Cyanoacrylate Glue

Accidental into the eye can cause the lids to

adhere and adhesive clumps to form on the cornea

Not permanently harmful to the eye

Cyanoacrylates are used occasionally directly on the
cornea to seal corneal perforations.
Cyanoacrylate Glue

Moisten the glue with eye ointment, and remove

as much as can be removed easily without causing
damage to underlying tissue

The glue will loosen and become easier to remove

in a few days.
Non-traumatic Ocular Emergencies
A 55-year-old woman with a red eye, blurred
vision with halos, nausea, and vomiting

The woman suddenly experienced nausea, vomiting, and extreme

pain in the left eye while in a movie theater. Her vision has
worsened since that time and the eye has become very red.
A 55-year-old woman with a red eye, blurred
vision with halos, nausea, and vomiting

Conjunctival injection
Hazy cornea
Shallow anterior chamber
Fixed mid-dilated pupil

IOP 56 mmHg

Acute Angle Closure Glaucoma

Anterior Chamber Depth
Acute Angle Closure Glaucoma

Reduce the intraocular pressure

O.5% Timolol 1 drop
2-4 % Pilocarpine 1 drop every 15 minutes
20% Mannitol 250-500 ml IV drip
Acetazolamide 500 mg oral
100% Glycerin 1 cc/kg

Consult ophthalmologist
A 60-year-old woman with acute, painless loss
of vision in the right eye

Central Retinal Artery Occlusion

Visual acuity CF LP in 90% of cases

Opaque white retina and attenuated vessels
Central Retinal Artery Occlusion

Treatment must be initiated immediately.

Ocular massage
Inhaled carbogen ( 95% O2 and 5% CO2 )
Reduced intraocular pressure

Consult ophthalmologist immediately

Anterior chamber paracentesis
Direct infusion of t-PA or urokinase in the
ophthalmic artery
A 40-year-old man with left eyelid edema and pain
( worse on eye movement )
A 40-year-old man with left eyelid edema and pain
( worse on eye movement )

Periorbital erythema and edema

Restricted extraocular motility
Decreased visual acuity

Orbital Cellulitis
Orbital Cellulitis

Broad spectrum intravenous antibiotics

CT scan orbit
Ophthalmology & ENT consultation

Subperiosteal abscess
Preseptal Cellulitis
Urgent Neuro-ophthalmology
A 36-year-old-woman with subacute visual loss in
right eye and pain on eye movement

VA 20/200, 20/25 RAPD +ve OD

VF central scotoma OD

Retrobulbar optic neuritis

A 55-year-old man with HT and acute visual loss in RE

VA 20/100, 20/20 RAPD +ve RE

ESR 10 mm/hr

Nonarteritic anterior ischemic optic neuropathy

A 73-year-old woman with acute visual loss of right
eye, headache, anorexia and weight loss

VA 10/200, 20/25 RAPD + ve RE

Arteritic anterior ischemic optic neuropathy

ESR 94 mm/hr, high level of C - reactive protein

Pathology : Giant Cell ( Temporal ) Arteritis
A 35-year-old man with left painful third nerve palsy

VA 20/25, 20/30
Dilated, nonreactive pupil LE
A 35-year-old man with a suspicious of aneurysmal
third nerve palsy

Conventional CT scan or MRI are not the

procedure of choice

High false negative rate 12 40 %

Magnetic resonance angiography (MRA)

Computed tomography angiography (CTA)

Overall sensitivity up to 97 %
A 35-year-old man with a suspicious of aneurysmal
third nerve palsy
A 40-year-old woman with sudden onset of left
third nerve palsy, visual loss and severe headache

VA 20/30, LP +ve RAPD LE

What is the diagnosis?

Pituitary Apoplexy

Characterized by sudden visual loss, headache,

and ophthalmoplegia secondary to rapid
expansion of pituitary macroadenoma into the
suprasellar space and/or cavernous sinus

Commonly results from hemorrhage into a pre-

existing pituitary mass
A 17-year-old man with right blured vision after
minor blunt trauma.

VA 20/32, 20/20 + ve RAPD RE

Normal fundi

A 16-year-old man with head injury and left
blured vision after falls from height

VA 20/30, LP + ve RAPD LE
Normal fundi
Traumatic Optic Neuropathy :
Classification and Mechanisms

Direct injury
- Penetrating injury from knife, projectile
- Injury from fractured bone
- Avulsion, transection

Indirect injury
- Contusion with transmission of force through bone
- Compression secondary to orbital hemorrhage or
intrasheath hemorrhage
Clinical Features of Traumatic Optic Neuropathy

Most commonly unilateral

May be overlooked in setting of significant

globe or maxillofacial trauma

Reduced visual acuity ( NLP to 20/20 )

Visual field defect : No pathognomonic defect

Normal optic disc with development of optic

Medical Management Options

Steroids : Controversial
- Thought to limit free-radical amplification

of the injury response

- Dosages ( low, high, mega)

- May be harmful

Observation : 57% of untreated patients shown

to have 3 lines or more acuity improvement
Surgical Management Options

Lateral canthotomy and cantholysis for orbital


Surgical decompression of the optic nerve

within its canal

There is no defined standard protocol of

treatment for indirect optic nerve injury .