Ophthalmologic Emergencies

Division of Emergency MedicineStanford School of Medicine

Challenges of Eye Complaints

• Similar complaints (redness, pain, visual changes) may represent benign or vision threatening etiologies

• Rapid diagnosis and therapy can be vision saving

• Visual loss is devastating for the patient and physician

• Most residents are uncomfortable with eye complaints

General Approach to Eye Complaints

• History- onset, trauma, history of same, discharge,

perceived vision, field defects, associated symptoms (halos, headaches), allergies

Physical Exam- Visual acuity, general inspection (pupils, obvious

foreign bodies, discharge, lid eversion), fundoscopy, visual fields, slit lamp (cornea, anterior chamber)

Everting the eyelid

Common Eye Lid Disorders

• Blepharitis- Acute or chronic eyelid

inflammation, causing crusting of the lids (infectious vs. allergic)

• Stye- Acute staph infection of an

eyelid follicle• Chalazion – meibomian gland

cyst (painless, non infectious) often confused with a stye

Causes of the “Red Eye”

Symptoms Signs

Conjunctivitis Bilateral (usually)

Gritty feeling (not pain)

Stickiness

Conjunctival hyperemia

Swollen lids

Mucoid Discharge

Iritis Unilateral (usually)

Lacrimation

Photophobia (Pain!)

Blurred vision

Reduced Vision

Cliary injection

Constricted pupil

Flare in AC

Keratitis/Foreign Body/Abrasion Unilateral (usually)

Lacrimation

Photophobia (Pain!)

Blurred vision

Reduced vision

Ciliary injections

Localised corneal opacification, abrasion or FB

Acute Glaucoma Unilateral (usually)

Lacrimation

Photophobia (Pain!)

Blurred vision

Headache, Halos, Vomiting

Reduced vision

Ciliary injection

Corneal edema

Dilated pupil

Raised IOP

Many causes of the “Red Eye”

• A middle-aged man comes in with complaints of a painful red eye.

• He said the pain developed after coming out of a movie theater. “It feels like a migraine” (headache, nausea, vomiting) “The lights have halos around them”

• What’s the probable diagnosis?

Acute Angle Closure Glaucoma

• What are findings on physical exam?– Visual acuity: – Conjunctiva:– Cornea:– Pupil:– Anterior

chamber:

What is the anterior chamber

Shallow anterior chamber

• How can you demonstrate a shallow anterior chamber?

• OBLIQUE FLASHLIHGHT TEST

Acute Angle Closure Glaucoma

• What is a normal intra-ocular pressure (IOP)?

• How do you measure the IOP?

Another “Red Eye”• Patient presents whose right

eye is red, painful and very sensitive to light.

• When you shine the penlight in her left eye, it causes her pain in the right (affected) eye.

• What diagnosis does it suggest?

Iritis

• What might you find on examination of the anterior chamber by slit lamp?– Headlights in the

fog– Dust in a sunbeam

Cell and Flare

My baby’s got pink eye

• A patient in a big hurry comes in to see you. She is disheveled and scantily dressed. She says, “my baby’s got the pink eye

• She has a 5 day old infant with a bilateral eyelid swelling and a thick purulent discharge from both eyes.

My baby’s got the pink eye

• Should you just give her the antibiotic drops?

• What’s the diagnosis?• Where did the baby get

the infection?• Does mom need to be

treated?

Eye pain and FB sensation

• A middle-aged man complains of a foreign body sensation in the left eye

• Fluoroscein staining of the cornea reveals the following lesions. Diagnosis?

• Should we initiate therapy with steroids?

• Complications?• Stain everyone!

Red painful eye in a contact lens wearer

• A patient who wears contact lenses presents with a painful red eye

• Diagnosis? • Treatment?

Eye pain in a contact lens wearer• Never patch a contact lens wearer

• Advisable to cover for Pseudomonas in a contact lens wearer

• No benefit to pressure patching in terms of rate of healing or pain reduction

Painful eye. Diagnosis?

Another red eye

• A three-year old child presents with erythema and swelling around the left eye.

• The Pediatric resident says, “It’s periorbital cellulitis; start the kid on antibiotics and send him home.”

• Are you comfortable with that?

Sudden painless visual loss

• The nurse has an elderly man with a history of CAD and TIA's who says he can’t see anything out of his left eye. The loss of vision was sudden and painless.

• What diagnosis does this presentation suggest?

Central retinal artery occlusion (CRAO)

• How long before this visual loss becomes permanent?

• Physical exam findings?– Visual acuity/field:– Pupillary exam:– Retina:

• Doctor, I see flashes of light and a curtain has dropped over my right lower visual field…

• Diagnosis?

• Doctor, I can’t see well out of my right eye. It’s hazy and there are floaters…

• Diagnosis?

Traumatic Conditionsof the Eye

Poked in the eye!

• A young boy presents to the ER after having been poked in the eye by another student.

• He is being seen by a resident who is just about to measure the child’s intra-ocular pressure when you yell “STOP!!!!!!”

• Why are you so uptight?• Now what should you do?

• Emergency Ophthalmology Consultation

• Protect the eye

• Avoid eye manipulation

• NPO

• Prophylactic antibiotics

• Update Tetanus

• Antiemetics

• Analgesics, Sedation

• Avoid Succinylcholine?

Open Globe Treatment

FB sensation

• A young male presents to the ER with foreign body sensation to this left eye.

• He was pounding a nail and felt something get into his eye.

• You examine patient and find that other than some photophobia, his exam is normal.

• You are about to discharge him when the attending says, hold on just a minute. What could you have possibly missed?

• How do you make the diagnosis?

Positive Seidel’s

• You carefully examine the patient and place fluorescein in his eye. You see the fluorescein streaming.

• What is this called? • What does it

signify?

Drain cleaner in the eye• A patient comes to the ER

having gotten some drain cleaner in her eye and it's causing her a lot of pain.

• The triage nurse tells her the wait to be seen is 1 hour and the patient becomes irate and starts to leave.

• You happen to overhear this conversation

• What should you do? Why?• Treatment?• How long?

Baseball versus eye

• A young male presents to the ER after having been hit in the eye with a baseball. He says, "I keep seeing double when I look up".

• Diagnosis?• Pathophysiology?• Treatment?

BLOWOUT FRACTURE

Symptoms:• Diplopia• Epistaxis

Signs:

• Crepitus/tenderness over orbital rim or maxilla

• Periorbital subQ emphysema • Limitation of EOM• Enophthalmos • Anesthesia of the ipsilateral

cheek and upper lip - WHY?• Periorbital ecchymoses/swelling

Pathophysiology

Blunt Trauma

• The patient may also have a hyphema

• Make sure to look with a slit lamp

• Some may be microscopic- Blurred vision- Risk of re-bleed, glaucoma

Blunt Trauma

• They may also have a subconjunctival hemmorhage or lens dislocation.

Eyelid laceration• A young child

presents to the emergency department with a small laceration of her left upper eyelid.

• What's that protruding from her laceration?

• What does it signify?

“Eyelids don’t have fat”

• Orbital fat usually protrudes through septal lacerations

• Fat in the lid laceration confirms the diagnosis

• High incidence of globe penetration and intraocular foreign bodies

• High risk for orbital cellulitis

Questions and Answers