Ophthalmologic Emergencies in the Office

Chemical burns

  1. The only ocular emergency where treatment should not be delayed to assess visual acuity
  2. Immediately irrigate the eye with normal saline or lactated Ringer’s (can use water if no other options).
  3. If over the phone tell the parent to continuously flush the eye. If the patient is at the office and you are unable to open the lids, placing a topical anesthetic will allow you to open the eyes and flush. Irrigate for about 20 minutes and have patient change gaze to allow total eye to be flushed. May need up to 10 L of fluid.
  4. Check pH by applying litmus paper to inside of lower eyelid where it touches the globe. Keep irrigating until eye pH is 7.0. If no pH paper at hand, irrigate for at least 30 mins.
  5. Check visual acuity
  6. Check for any corneal changes by staining with fleurocein drops. Give cycloplegic (scopolamine) and broad-spectrum antibiotic eye drop.
  7. Immediately refer to ophthalmologist or ER. Tell parents to continue eye wash en route.

 

Trauma

  1. More common in boys due to sports, occupations
  2. Globe rupture
    1. Hyphema- blood in the anterior chamber and will see blood layering. May see blood 360 degrees around cornea. May be associated with global injury and about 30% will rebleed leading to acute increase in intraocular pressure.
      QgVlUwi_0.jpg
      https://www.reddit.com/r/WTF/comments/1li1p4/hyphema/
    2. Increased intraocular pressure can cause extrusion of contents, so give analgesia and anti-emetics
    3. Positive Seidel test on slit lamp examination
    4. Cover with eye shield
  3. Orbital Fracture
    1. Diplopia, pain with extraocular movements
    2. Proptosis – hematoma behind eye. Limited EOM movements – entrapment of extraocular muscle.
    3. Evaluate for globe rupture, retinal hemorrhages, reduced visual acuity.
  4. Give prophylactic antibiotics. Immediate referral to ophthalmologist or ER.
  5. Intraocular Foreign Body- There may be minimal symptoms. Patient's activity at time of accident most important. Often working with drilling or hammering and sudden impact feeling.
    1. Check visual acuity
    2. Check for laceration of the globe, hyphema, pupil changes.
    3. Refer to ophthalmologist.
  6. Corneal Foreign Body- Foreign body sensation. Increased tearing, conjunctivitis, and light sensitivity. If the onset of symptoms is gradual, suspect keratitis of infectious etiology often associated with wearing contacts or viruses. 
  7. Conjunctival Foreign Body- May see under the lid, usually tarsal. To see may put topical anesthetic in eye. Using cotton applicator, roll the lid over the applicator and then try to scrape with the cotton applicator. May use side of 25 gauge needle to remove. Should also check for corneal abrasion.
  8. Corneal Abrasion- excruciating pain, tearing, inability to open eye
    1. Examine with pen light to rule out penetrating trauma or blood. Confirm pupils are round, reactive, and central.
    2. Check visual acuity
    3. Topical anesthetic to give patient comfort and allow exam
    4. Stain with fleuroscein
    5. Give an antibiotic, cycloplegic (relax ciliary apparatus), and patch to decrease irritation due to blinking. If the abrasion is above the midline, suspect a foreign body under the upper lid. Can also give analgesics by mouth. Encourage the parents and patient to keep the patch on but often difficult. Usually better within 24 hours.
    6. If not improving or very deep, ophthalmology referral.
    7. Although topical anesthetics like proparacaine and tetracaine will give relief, there use causes corneal thinning and may lead to blindness. Never prescribe to patients. 
  9. Proptosis- forward displacement of the globe due to increased soft tissue or bone.
    1. Graves disease
    2. Tumor
    3. Orbital cellulitis
    4. Orbital fracture with retro-orbital hematoma
    5. Urgent referral if
      1. Unilateral
      2. Acute
      3. Painful
      4. Decreased eye movement
      5. Decreased visual acuity
  10. Cellulitis
    1. Common organisms are Streptococcus pneumoniae, Group A beta hemolytic strep, and H.influenzae.
      1. Consider S. aureus, especially if recent trauma (surgery, scratch, insect bite)
    2. Preseptal cellulitis
      1. Periorbital edema and erythema
      2. No pain with eye movement, visual acuity normal
      3. Usually antecedent skin trauma or sinus infection
      4. Tx: PO Amoxicillin-clavulanate x 2 weeks
    3. Orbital cellulitis
      orbital-cellulitisc200pxw.jpg
      http://sinusitisunderstood.blogspot.com/p/complications-and-referal.html
      1. Swelling of the eyelids and conjunctiva, limitation of eye movement with pain, decreased visual acuity, toxic appearing, proptosis
      2. Usually antecedent sinus infection
      3. Treatment must be quick to prevent development of abscess within the orbit and spread to the CNS, optic nerve, and development of meningitis and brain abscess.
        1. Hospitalize immediately for IV antibiotics

References

  1. Golden DJ. Globe Rupture. Emedicine. 18 February 2010. http://emedicine.medscape.com/article/798223-overview. Accessed 8 December 2011.
  2. Harrington JN. Orbital Cellulitis. Emedicine. 10 October 2011. http://emedicine.medscape.com/article/1217858-overview. Accessed 12 December 2011.
  3. Jacobs DS. Corneal abrasions and corneal foreign bodies.  UpToDate. 14 October 2011. http://www.uptodate.com/contents/corneal-abrasions-and-corneal-foreign-b.... Accessed 5 December 2011.
  4. Neuman MI, Bachur RG. Orbital fractures. UpToDate. 14 July 2011. http://www.uptodate.com/contents/orbital-fractures. Accessed 5 December 2011.
  5. Pokhrel PK, Loftus SA. Ocular Emergencies. Am Fam Physician 2007;76:829-36.
  6. Sobol AL. Preseptal Cellulitis. Emedicine. 17 March 2011. http://emedicine.medscape.com/article/1218009-overview. Accessed 10 December 2011.
  7. Tingley DH. Consultation with the Specialist: Eye Trauma: Corneal Abrasions. Pediatrics in Review. 1999; 20:320-322.
  8. Hoffman Robert. Evaluating and Treating Eye Injuries. Contemporary Pediatrics April 1997
  9. Wilson S. Last A. Management of Corneal Abrasions. American Family Physician July 1, 2004

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