Educational Articles
OPHTHALMOLOGICAL EMERGENCIES

Eye complaint visits to the ED are a relatively small percentage of total visits based on statistics from the CDC for the years 2007-2010. The majority of these cases are in children and adults older than 65 years old. While the overall number of visits is low, the potential for serious problems exist due to the organ involved and the potential end complication ultimately being blindness.

Our first question or priority should be is there vision loss or trauma. Secondly, most visits can be further divided into external and internal as related to anatomy. For this article, we will divide the subject into external and internal as it relates to medical issues and trauma.

External medical: we can start with blepharitis or inflammation/infection of the eyelid usually caused by staphylococcus. Treatment for most external medical complaints includes gentle soap washing and topical antibiotics. Another reason for visits to the ED is a Hordeolum or "Stye". It is usually found along the lid edge or margin and is erythematous and painful. Treatment is warm compresses, gentle soap washing, and topical antibiotics. A very close mimicker of the stye is the chalazion. This is usually involves the mid portion of the upper lid midway and not the lid margin. It is non-tender and not erythematous or inflamed. Again, warm compresses topical antibiotics and referral to an ophthalmologist for I&D. Another reason or diagnosis we need to be familiar with is Dacryocystitis, which is an infection of the lacrimal sac usually caused by a staph infection. This is characterized by a swelling to the inferior-medial aspect and is tender with purulent drainage. Treatment is systemic or topical antibiotics and decongestants with referral. If you have swelling and tenderness to the superior-lateral aspect, you might have dacrayoadenitis, an infection of the lacrimal gland. Treatment is antibiotics, warm compresses with referral for possible I&D. You can have both also, dacryocystitis-adenitis.
The majority of visits to the ED are for swelling and redness of the soft tissue around the eye, cellulitis. Cellulitis can be classified as periorbital or orbital depending on the anatomy involved. The infectious causes are staphylococcus or streptococcus. Periorbital infections are usually differentiated from orbital cellulitis clinically based on a lack of tenderness with eye movement. With periorbital cellulitis you can get fever, lid edema and erythema. It is recommended to do a septic workup on children younger than 5 years of age. Treatment is systemic antibiotics directed at causative agents usually Augmentin, Vancomycin or Rocephin.

Orbital cellulitis is a true emergency. Patients look sick or toxic, there is moderate to severe pain with eye movement along with decreased movement. The eyelid will be dark red and swollen. There is decreased visual acuity and increased IOP along with fever. Normally caused by H.flu or staphylococcus. Sinusitis is usually a precursor to the development of this disease. Workup should include blood cultures, CT of the brain and orbits and consider lumbar puncture (as one complication is meningitis). Treatment should include IV antibiotics (cefuroxime or ceftriaxone) consult and admit.

Trauma to the external lid, especially involving the lid margin, needs close inspection and normally is beyond our scope of practice as there are consequences if the lid is not perfectly approximated once the laceration heals. Another reason an ophthalmologist needs to evaluate these cases of trauma is to make sure the lacrimal system is intact from the gland to the sac. If the trauma/laceration involves the inferior/superior-medial aspect, it is extremely possible to disrupt the punctas.

Red eyes are another reason people visit the emergency department. Red eyes that are painful, non-painful, acute or chronic all show up in one form or fashion. It is our job to sort out and determine the proper treatment and course. We can use the acronym "CFUNK": Conjunctivitis, Foreign body, Uveitis/Iritis, Narrow angle glaucoma, and Keratitis.

Conjunctivitis AKA "Pink Eye" is an infection or inflammation of the eyes that can be caused by either viruses or bacteria. The major viral cause is adenovirus. It usually starts in one eye and migrates to the other eye, has a thin watery drainage, and there is usually a URI present as well. Visual acuity and IOP are in normal range. The viral cause is self-limiting and requires no treatment other than warm compresses and hand washing in simple conjunctivitis. You can have epidemic keratoconjunctivitis caused by a virulent Adenovirus strain. This is severe conjunctivitis that lasts 2-3 weeks and is associated with a decreased visual acuity. This needs ophthalmology consult as steroids are typically used to treat. Bacterial causes typically have a purulent drainage is usually unilateral. However, it can be bilateral due to self-inoculation. The usual causative agents are strep, staph, GC, or H. flu. If there is a rapid progression, topical antibiotic drops q 2-3 hours is the treatment of choice with ophthalmology consult.

Foreign bodies can be anything biologic, organic and non-organic and each have a variety of complications. Careful examination starting with visual acuity and fluorescein staining, woods lamp and slit lamp examination are required as certain patterns can guide treatment and identify any retained FB such as metal splinters. Multiple vertical lines are a good indicator of retained FB under the upper lid. Lid eversion must be done to do a thorough exam. CT is required if globe penetration is suspected. Rust rings can be removed in the ED or if needed, consult or referral to ophthalmology to remove the ring. Remember you don't patch the affected eye due to an increased risk of infection. Use cycloplegics for pain control not a prescription for topical analgesics. Systemic meds for pain control is ok for short duration. Topical antibiotics should be directed towards potential causative agents. Don't forget to provide tetanus prophylaxis.

Uveitis/Iritis is the inflammation of the iris, ciliary body or choroid. There are several considerations as to the cause. The causes can include trauma and infection. Physical findings include redness to varying degrees, cells and flare under slit lamp exam along with miosis. Generally patients complain of a "deep ache", decrease visual acuity, and photophobia. Treatment includes topical steroids, analgesics, and pupil dilatation along with referral for very close follow-up.

Narrow angle glaucoma (AKA acute angle closure glaucoma) is the "N" and consists of a blockage of the aqueous flow in the eye. Patients complain of pain, decreased visual acuity (blurred vision), "halos" in their vision, headaches, and nausea. On exam, they will have a red eye with a non-reactive, mid-dilated pupil. IOP will be elevated to 40-70 (normal is 10-21). On slit lamp exam, you will notice an iris that is bulged forward. Treatment is geared towards decreasing the IOP by decreasing the aqueous production. We use a combination of medications, a topical beta-blocker (timolol), an alpha agonist and Acetazolamide IV. Mannitol 1gm/kg can also be given to osmotically decrease IOP. Pilocarpine is used as a topical miotic, but only after IOP is reduced.

Keratitis is the inflammation of the cornea and can be caused most commonly by infection, exposure (arch burn or snow blindness) or drugs. Keratitis caused by infection can be extremely serious and result in loss of vision. Any white spot on cornea should be treated as a corneal ulcer and are bacterial until proven otherwise. Often times, there may be a hypopyon associated with keratitis associated with infections. This requires topical and IV antibiotics and emergent consult/referral. UV keratitis is typically found in welders or exposure to high intensity arching. Usually both eyes are affected, and the typical presentation is a delayed onset with extremely painful eyes. On physical exam, you may note micro lesions (picture golf ball dimples) to cornea. Treatment is patching, pain medication and cycoplegics. Another high-risk cause of keratitis is herpes zoster ophthalmicus (HSV). If on exam you see Hutchinson's sign (lesion on tip of nose from zoster), you should be highly suspicious for the presence of ocular involvement. Careful exam, including fluorescein exam under slit lamp for dendritic lesions, is warranted even if the eyelid is normal. Treatment includes antivirals and emergent consultation of an ophthalmologist.

Trauma to the eye can take many forms from a simple blunt force (BFT) to a chemical burn to a ruptured globe. You can have anything from a subconjunctival hemorrhage (normally a spontaneous event), retinal detachment to major globe injury - a ruptured globe or alkali/acid chemical exposure.

Subconjunctival hemorrhage is self-limiting and nothing needs to be done for it. Rule out a zygomatic fracture if history indicates BFT to the area. Corneal lacerations are often subtle and may have a distinct tear drop shaped appearance to the pupil. Do not use tonometry pen to check IOP if a lacerated cornea, globe penetration or ruptured globe is suspected. You may do a Seidel Test - Fluorescein stain applied to the eye, and it spontaneously washes away due to leaking aqueous fluid. Do not put a patch, but place a shield around the eye and get an emergent consult. Treatment includes IV antibiotics, pain meds, CT/MRI and tetanus if needed.

Chemical burns can be divided into either acids or alkali burns. Alkali burns are worse than acid burns and cause liquefaction necrosis. Immediate irrigation is needed and in some cases 24 hours of irrigation is done as alkali compounds continue to burn until completely neutralized to a pH of 7.4. Acids cause coagulation necrosis and usually are not as severe or deep as alkali burns. Treatment is irrigation and monitoring pH.

Blow out fractures are common with direct blunt force trauma and can be detected with x-rays or CT. Suspect an orbital blow out fracture, if on exam, you have deficits in inferior or superior gaze or a non-reactive pupil with a history of BFT. A consult or referral is needed to preserve function and vision. Retrobulbar hemorrhage is another possibility with trauma and needs emergent decompression of the exophthalmos because you get a build up on pressure to the globe decreasing retinal blood flow and causing irreversible ischemia. On exam, you have decreased vision, a dilated non-reactive pupil, exophthalmos and proptosis. Treatment is a lateral canthotomy along with medications to decrease IOP and immediate consult.

This article has been only a short overview of the various ophthalmologic conditions that present most commonly or are especially high risk for emergency physicians. Having a good fund of knowledge of these conditions, a systematic and consistent approach to the physical exam of the eye, and an appropriate understanding of when to consult is extremely important when taking care of these conditions.

*References available upon request.