OPHTHALMOLOGY PRESENTER :

Ili Nabihah
See Jit Ping Eugene

EMERGENCIES SUPERVISOR :
Dr. Khairul Izwan
Dr. Anas
The Bony Orbit
The extraocular muscles
The eyeball Anterior segment:
• Conjunctiva
• Cornea
• Anterior sclera
• Aqueous humor
• Iris
• Lens
• Anterior chambers

Posterior segment:
• Vitreous body
• Retina
• Choroid
• Posterior sclera
• Optic nerve
Clinical Approach
Several common eye symptoms :
1. Decreased vision in one or both eyes, sudden or gradually blurring or complete
loss of vision
2. Red eye (painful/painless)
3. Any other specific eye symptoms, such as double vision, swelling of an eyelid,
tunnel vision, foreign body
4. Eye discharges
History of presenting complaint

For each complaint, ask about:

•Onset (sudden or gradual)
•Course (how it has progressed)
•Duration (how long)
•Severity
•Location (involving one or both eyes)
•Any relevant associated symptoms
•Any similar problems in the past
Examination of the eye

6 steps in an eye examination :

1. Visual acuity - Done with Snellen Chart.

2. Visual field - test each eye separately. By using the confrontational method.
3. Pupils - Assess the pupils for size, shape, reactivity towards light
4. Extraocular eye movement - Asses the 6 cardinal positions of gaze and presence
of nystagmus
5. Eye lids and anterior segment -Examine the eyelids, conjunctiva, sclera, cornea,
iris, lens and anterior chamber with a pen torch.
6. Posterior Segment - Using ophthalmoscope, visualize red reflex, optic disc, retinal
vessels.
Visual acuity

•Snellen chart x/y

•X is distance from chart (ie 6 metres)
•Y is smallest font size read
•Eg Normal 6/6, just top line 6/60
•If the patient reads the 6/6 line but gets 2 letters
incorrect, you would record as 6/6 (-2).
•If the patient gets more than 2 letters wrong,
then the previous line should be recorded as their
acuity.
•When recording the vision it should state
whether this vision was unaided (UA), with
glasses or with pinhole (PH).
Ophthalmoscope examination
Fluorescein
eye stain test
 Blunt

Trauma
Penetrating

Burns
Ophthalmology (Chemical,
emergencies Thermal)

Infectious
Non-Trauma
Non-
infectious
Traumatic Ocular emergencies
Non-traumatic Ocular emergencies
1)Blunt trauma to the Eye, Adnexa,&
1)Non infectious:
Orbit:
• Acute Angle-Closure Glaucoma
• Lacerations of the Eyelids
• Central Retinal Artery Occlusion
• Orbital hemorrhage
• Central retinal vein occlusion
• Orbital fracture. Eg: Blowout fractures
• Vitreous hemorrhage
of the floor of the orbit,
• Retinal hemorrhage
• Corneal Abrasions/ corneal ulcer
• Uveitis ( iritis & iridocyclitis )
• Corneal & Conjunctival Foreign
• Spontaneous subconjunctival
Bodies
hemorrhage
• Ruptured globe
2)Penetrating injury
2) Infectious
• conjunctival/scleral /corneal
• Preseptal cellulitis
perforation
• Orbital cellulitis
• Ruptured globe
• Endophthalmitis
3)Burns
• Orbital abscess
• Alkali chemical
• Stye/ chalazion
• Acidic chemical
• Blepharitis
• Thermal
• Conjunctivitis (viral/bacterial)
Non Trauma Ocular Emergencies
Differential diagnosis of gradual vision loss

Painless
Common
• Cataract
• Age-related macular degeneration
• Slowly compressing lesions involving
the orbit or intracranial space

Rare
• Slowly progressive inflammatory or
neoplastic processes (e.g. optic
granuloma, optic neuroma)
Differential diagnosis of acute vision loss

Unilateral, painless Bilateral, painless

• Vitreous haemorrhage • Usually from acute refractive exacerbation, such as
• swelling of lens
Retinal haemorrhage
• Poor control DM
• Retinal detachment • Medication (e.g. anticholinergic, steroids)
• CRVO
• CRAO

Unilateral, painful
• Corneal abrasion
• Corneal ulcers Bilateral, painful
• Uveitis • Usually trauma to the anterior segment
• Traumatic hyphema • Chemical exposure
• Ultraviolet radiation exposure
• Acute Glaucoma
• Orbital cellulitis
• Keratitis
• Optic neuritis
• Migraine
Differential diagnosis of red eye

Painful red eyes Painless red eyes

• Acute angle-closure glaucoma • Conjunctivitis
• Scleritis • Subconjunctival haemorrhage
• Uveitis • Episcleritis
• Keratitis
• Corneal Abrasion/corneal ulcer
• Trauma/chemical injury
Vitreous Haemorrhage
• Symptoms : Sudden onset of painless blurry vision, floaters, blindness
• Causes : Proliferative diabetic retinopathy, posterior vitreous detachment,
trauma injury
• Examination : Vitreous floaters and blood ophthalmoscope
• Management : Place patient in upright position, consult ophthalmologist
Retinal Haemorrhage
• Symptoms : Acute focal or generalized lost of vision, painless
• Causes : Diabetes, High blood pressure, anemia, leukemia, head trauma,
rapid change in air pressure
• Examination : Retinal haemorrhage on ophthalmoscope
• Management : Consult ophthalmologist
Retinal Detachment
• Symptoms : Acute lost of vision, with flashes of light, tunnel vision, curtain
like shadow over visual field
• Causes : Advanced diabetes, aging, extreme near sightnedness, post
cataract surgery
• Examination : Grey folded area of retina overlying vessels on
ophthalmoscope
• Management : Consult Opthalmologist
Ocular USG for retinal detachment
• A 'Macula on' is retinal detachment that doesn’t involve the macula and optic
nerve (Occular emergency)
• A 'Macula off' is retinal detachment that involves the macula and optic nerve
Central Retinal Artery Occlusion
• The most common presenting complaint of
(CRAO) is acute, unilateral, persistent, painless
vision loss
• Cause : Emboli dislodged from the carotid
artery is the most common cause, from either an
unstable atherosclerotic plaque or a cardiac
source.
Examination:
- RAPD of affected eye
- Pale/swollen optic nerve with splinter
hemorrhages.
- Cherry-red spot and a ground-glass retina
• Management: Urgent referral to ophthalmology,
paper bag rebreathing, intermittent globe
massage
Central Retinal Vein Occlusion
• Retinal vein occlusion (RVO) is a common cause of vision loss in older individuals,
• The pathogenesis is believed to follow the principles of Virchow’s triad for
thrombogenesis, involving vessel damage, stasis and hypercoagulability
• Risk factors include:
- Hypertension
- Diabetes mellitus
- Smoking
- Taking oral contraceptives
- Raised IOP
- Connective tissue disease
Two types: Non-ischemic and ischemic type
Management: Referral to ophthalmologist,
reduce inflammation(systemic
corticosteroids/local corticosteroids)
Acute angle closure glaucoma

• AACG occurs as a result of the impaired drainage of aqueous humor and

subsequent pathologic increase in IOP
• Symptoms : Red eyes, blurring of visions with halo, headache, nausea and
vomiting
• Examination : Decreased visual acuity of affected eye, hazy cornea, fixed
mid dilated pupil, conjunctival injection
 Narrow angle

Several anatomic
abnormalities which can lead
Shallow anterior
to anterior chamber
chamber
crowding:
Overdevelope
d iris dilator
muscle
Short axial
Increased
eye length
contact
between lens
and iris
Other causes:
-drugs: sympathomimetics,
anticholinergics,
antidepressants [SSRIs],
anticonvulsants,
sulfonamides, cocaine, Thickened lens
botulinum toxin 26Anteriorly situated lens
 Management
• Urgent referral to
ophthalmologist when acute
close angle glaucoma is
suspected.
• Can be treated using
medical treatment
• If fail, proceed to laser
treatment (laser iridotomy,
laser peripheral iridoplasty)
and surgical treatment (lens
extraction, combined
trabeculectomy and lens
extraction)
 Conjunctivitis
• Inflammation of the bulbar and/or palpebral conjunctiva (the transparent lubricating mucous
membrane that covers both the surface of the eye and lining of the undersurface of the
eyelids)
• Symptoms : Red eye, Irritation, itching, and a sensation of foreign particle in the eye,
discharge from eyes that makes opening the eyes difficult in the morning, light sensitivity,
blurred vision
• Examination : Conjunctival injection, purulent eye discharge, eyelid edema
• Causes : Bacterial , viral, allergic conjunctivitis

• Prevention: Hygiene and avoidance of close patient contact, avoid sharing napkins, towels,
pillow cases, and linens, wash hands often and avoid contaminating public swimming pools.
Workers and students often are excused from work or school
PRESEPTAL (PERIORBITAL) CELLULITIS
•Refers to infection occurring anterior to the orbital septum
•Usually associated with upper respiratory tract infections,
especially paranasal sinusitis, and also from eyelid problems
such as hordeolum, chalazion, insect bites, and trauma
• Sx : URTI, LG fever, redness and swelling of the eyelid, and
excessive tearing (epiphora)
• Examination : Visual acuity, pupillary reaction, and full
painless ocular motility is preserved.
• Mx : oral antibiotics (amoxicillin/ clavulanic acid or a first-
generation cephalosporin), hot packs, and close follow-up in
24 to 48 hours
POSTSEPTAL (ORBITAL) CELLULITIS
• Refers to infection occurring posterior to the orbital septum
•Frequently from the spread of paranasal sinusitis
• Factor : Trauma, intraorbital foreign body, spread of
periorbital skin infection, seeding from bacteremia, and ocular
surgery.
• Sx :Insidious onset with preceding upper respiratory
symptoms, including rhinitis, facial pressure, and fever, also
complain of pain when moving the eyes.
• Examination : limitation of extraocular muscle movement ,
chemosis, proptosis, abnormal pupillary response, and
decreased visual acuity.
• Mx : immediate ophthalmologic consultation & coverage with
broad spectrum abx
Periorbital and Orbital cellulitis
• Unilateral erythema, swelling, warmth, and tenderness of the eyelid can be seen in both periorbital
and orbital cellulitis.
• Blurred vision, ophthalmoplegia, proptosis, and chemosis help identify orbital cellulitis because they
are signs of increased intraorbital pressure, which should not be present in periorbital cellulitis.

• Difference between orbital and periorbital

cellulitis is based on the anatomical structure
of orbital septum.
• If a patient has inflammation of orbital septum
and everything superficial to it, it is diagnosed
as periorbital cellulitis and treated as outpatient
with oral antibiotics
• However if the structures posterior to the
septum are also involved, it is diagnosed as
CT image of Orbital cellulitis orbital cellulitis and requires opthalomologist
- Intraorbital free air
consultation and hospital stay.
- Diffuse fat infiltration
ENDOPTHALMITIS
• Inflammation (usually infectious) of the aqueous or vitreous humor.
• Cause : postsurgical, followed by penetrating ocular injuries.
• Symptoms : headache, eye pain, photophobia, vision loss, and ocular
discharge
• Examination : erythema and swelling of the lids, conjunctival and scleral
injection, chemosis, hypopyon, and evidence of uveitis.
• Management : immediate ophthalmologist consultation for aspiration of
the vitreous or pars plana vitrectomy, and administration of intravitreal
antibiotics and steroids.
Scleritis

• Symptoms : Severe pain, worse with eye movement, blurring of vision, teary
red eye. Headache
• Causes : Wegner's granulomatosis, SLE, Rheumatoid arthritis
• Examination : Dilation of episcleral vessels, bluish discoloration
• Management : Initiate oral NSAIDs and consult ophthalmologist
Uveitis
• Symptoms : Sudden painful red eye, worse with eye movement,
photophobia, conjunctival injection and sometimes blurred vision
• Causes : Autoimmune disorders like rheumotaoid arthiritis, ankylosing
spondylitis, trauma
• Examination : Perilimbal injection. Water discharge, consensual
photophobia( pain on affeted eye when light shone into non affected eye.
• Management : corticosteroids eye drops and consult opthalmologist
Keratitis
• Symptoms : Photophobia, foreign body sensation, tearing pain
• Causes : Contaminated contact lenses, chemicals in the water in swimming
pools, dry eyes, weakened immune system, eye injury
• Examination : Perilimbal injection, cells and flare in anterior chamber on slit-
lamp test, hypopyon in severe cases
• Management : Antibiotics eye drops and consult ophthalmologist
Traumatic Ocular Emergencies
 A case of painful red eye post trauma
A 10-year-old girl presented to the emergency department
with right ocular redness, ocular pain and visual disturbance
over the right eye. The girl gave history of eye trauma at
school by a sharp object while playing with friends
o/e:
- Visual acuity of right eye: counting fingers, (left eye normal)
- Right eye appears enopthalmos
- Severe conjunctival chemosis and raised subconjunctival
haemorrhage
- Corneal edema,
- Vertical linear corneal laceration extending from 12 o’clock
towards 5 o’clock with positive Seidel sign
-Teardrop shape pupil
- Total hyphema
RUPTURED GLOBE / PENETRATING TRAUMA
Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted
by blunt or penetrating trauma

A CATASTROPHIC injury that must be identified

SYMPTOMS:
 Severe subconjuctiva haemorrhage
 Shallow/deep anterior chamber
 Hyphema
 Teardrop-shaped pupil
 Limitation of extraocular motility
 Extrusion of globe contents
 Significant reduction in visual acuity
Examination:
• A bright green streaming appearance in Seidel Test is pathognomonic
• CT scanning of the eye is the preferred modality for further assessment of
occult open globe injuries.

Management :
• Cover the eye with a eye shield
• Consult ophthalmology immediately without further
manipulation
• Give tetanus immunisation, analgesics, antiemetics,
broad spectrum antibiotics
 HYPHEMA
• Hyphema is a collection of blood in anterior chamber
• Source: the iris root/ ciliary body
• Caused by blunt ocular injury
• Management: -protective eye shield
-elevating patient’s head,
-bed rest
-urgent referral to ophthalmology

41
 CORNEAL LACERATION
• Identified by a misshapen iris, macro- or
microhyphema, decrease in visual acuity, and
shallow anterior chamber
• •
A history of eye irritation while working with
metal fragments or high-speed machinery
• Ix : slit lamp examination
• Mx : if suspicion of penetrating injury, obtain a
CT of the orbit to identify changes in globe
anatomy/contour/foreign body within the
globe, and consult ophthalmology.
CORNEAL ABRASION
• Caused by contact lens wear, fingernails,
makeup brushes, and foreign objects blown
into eyes.
Sx : foreign body sensation, photophobia, and
tearing, pain
• Relief of pain with topical anesthesia is
virtually diagnostic.
• Superficial, irregular corneal defect appearing
bright green under the cobalt blue light after
instillation of fluorescein
CORNEAL FOREIGN BODY
 EXAMINATION
SYMPTOMS -Inspection: edema of the
-complain of burn and eyelid, redness over the
irritation during blinking corneal
-tearing -Torch light: noted foreign
bodies, “rust ring”
-blurred of vision appearance
-photophobia -Slit lamp: a corneal foreign
bodies are identifiable
MANAGEMENT
-All patients should be
REFERRED to an
ophthalmologist within 24
hours
-Full-thickness corneal
foreign bodies should be
removed by ophthalmologist
ORBITAL (RETROBULBAR) HEMORRHAGE
• Rapid sight threatening emergency which results in accumulation of blood in the orbital
space.

• Associated risk of acute orbital compartment syndrome with compressive optic neuropathy

• Causes : Orbital trauma, Complication of eyelid or orbital surgery, arteriovenous

malformation, orbital varicosities.

• Symptoms : eye pain, periorbital ecchymosis,

eyelid haematoma, opthalmoplegia, proptosis,
visual loss, subconjuctival haemorrhage.

• Treatment : emergency ophthalmology consultation

& emergency lateral canthotomy.
EYELID LACERATION
• Any eyelid laceration has a penetrating eye injury potential until proven otherwise

• On examination laceration wound should be explored to know the full extend of injury

• Orbital Xray/CT scan is indicated if suspected intraocular foreign body or blowout fracture
Management:

-Tetanus prophylaxis should be given

-Indication of referral to opthal team:
• Any eyelid laceration other than superficial skin that involves lid margin/ 6-8mm of the
medial canthus/ involving lacrimal duct/ inner surface of the lid
• Extensive tissue loss
• Distortion of anatomy
• Presence of ocular foreign body

-For simple superficial laceration,

toilet and suturing could be done in ED
with non absorbable sutures
ORBITAL BLOW OUT FRACTURE

• Most frequent sites of orbital blowout fractures are the inferior wall
(maxillary sinus) and medial wall, it may occur in lateral and superior wall.
• About one third of blow-out fractures are associated with ocular trauma .
• Other common causes ; MVA, sports, aggression
Two main theories to explain blow out fractures of
the orbital wall:

51
 MANAGEMENT

• Refer ophthalmology team

• Non surgical treatment : with broad spectrum antibiotics, ice packs and
prednisolone to reduce edema if no indication for surgical intervention

• Surgical treatment indications:

-Retrobulbar haematoma
-Diplopia
-Enopthalmos >2mm
-Substantial soft tissue herniation
-Displaced fracture
CHEMICAL INJURY
• True ocular emergency

• Distinction between acid and alkali exposure must be made

• Severity depends on: properties of chemical, area of affected

ocular surface, duration of exposure and related effects.
Alkali penetrates more deeply than acid

• Distinction between acid and alkali exposure must be made!

– Acid burns- coagulation necrosis superficial injury.
– Alkali burns- liquefaction necrosis  deep injury.

• Symptoms:
-extreme pain
-foreign bodies sensation
-blurred vision
-excessive tearing
-photophobia
-red eye
54
1. Emergency treatment without first taking history and examination.
• Copius irrigation with NS/Ringer Lactate (at least 4L) for 15-30 min or until pH is
neutral (tap water if necessary to avoid delay)
• Minimize duration of contact
• Normalize pH
• Faster action  good prognostic factor
• Instilled a topical anaesthetic / Morgan lens  comfort n cooperation
• Double-eversion of upper eyelid
• Identify n remove particulate matter trapped
• Debridement of necrotic area
• Promote re-epitheliazation
• Remove chemical residue

2. Analgesic, antibiotic, cycloplegic medications

3. Referred to ophthalmologist
REFERENCES

• Tintinalli’s Emegercy Medicine Manual 8th Edition

• Kanski’s Clinical Opthalmology: A Systemic Approach 8th

Edition

• Shirley Ooi Emergency Medicine

Thank you