TRAUMATOLOGI, FK-UNHAS
Ocular Emergencies
{
Review ocular anatomy
Understand basic ophthalmic workup
Know differential for:
Red eye
Recognize and manage common ocular
emergencies
Objectives
Anatomy of the Eye
www.jaapa.com
Near vision card
Penlight with blue filter
Topical anesthetic
Fluorescein strips
Topical mydriatic
Useful Tools
Visual acuity - Snellen eye chart, counting fingers, light
perception
CN II – VII - Pupils, visual fields, EOMs, facial droop
Inspection/palpation of eye and surrounding structures -
Asymmetry, proptosis, enophthalmos, orbital rim
Lids/ducts
Slit lamp – Anterior segment
Fundoscopy – Posterior segment
Contraindications to dilation – significant head trauma,
Eye Exam
suspected rupture, history of glaucoma
Intraocular pressure - Goldman applanation tonometry,
Tonopen
Perform at slit lamp
If not available, use ophthalmoscope
Inspect
Conjunctiva
Cornea
Anterior chamber
Iris
Lens
Anterior Segment
Estimating Anterior Chamber
Depth
Measures the intraocular pressure by
calculating the force required to
depress the cornea a given amount
with a tonometer.
IOP 10-20 is considered normal.
In chronic open angle glaucoma, IOP
can be 20-30, and in acute angle
closure glaucoma, IOP can be greater
than 40.
Tonometry
Measures both the direct and consensual
response of pupil to light.
Step 1: Shine light in right eye. This will
cause BOTH right and left pupils to constrict
via CN III through Edinger-Westphal
nucleus.
Step 2: Then swing pen light to left eye and
check to make sure the left eye
CONSTRICTS. If it constricts, this means that
the LEFT CN II is intact and is causing a
direct pupillary reflex. If it dilates, then this is a
sign that the LEFT retina or optic nerve is
damaged and is called an Afferent pupillary
defect. (APD)
The Swinging Flashlight
Test
Examine
Vitreous
Optic disc
Retinal vessels
Macula
Posterior Segment
Key worrisome clinical findings (ophtho
referral needed):
Pain: Pain in eye often indicates more
serious intraocular pathology (iritis,
glaucoma).
Visual acuity: if decreased, usually more
serious cause.
Pupil: if sluggish, worry about acute
glaucoma
Pattern of redness: CILIARY FLUSH
(Redness worse near cornea, usually serious
intraocular cause: iritis or glaucoma).
Algorithm for Diagnosing Red
Eye
Injection of deep
conjunctival vessels
and episcleral vessels
surrounding the
cornea.
Seen in iritis
(inflammation in the
anterior chamber) or
acute glaucoma.
NOT seen in simple
conjunctivitis
Ciliary Flush
Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by
the American Academy of Ophthalmology
DO YOU HAVE PAIN?
Biggest distinguishing Main differential of red
factor between emergent eye:
and non-emergent Conjunctivitis
Do you wear contacts? (infectious/noninfectious)
(increased risk of Trauma, Foreign body
keratitis-corneal infection) Subconjunctival
hemorrhage
Do you have any Angle closure glaucoma
associated symptoms? Iritis/uveitis
Red
Eye: Key historical
Decreased vision
photophobia/diplopia
Kerititis
Scleritis, episcleritis
questions
flashes/floaters
Halos/N/V/Abd pain
Any above require referral
Orbital Blowout Fracture
Signs & Sx’s:
Enophthalmos
Diplopia
Impairment of eye
movement 20 to EOM
entrapment, orbital
hemorrhage or nerve
damage
Orbital emphysema
Infraorbital n. anesthesia
CT should include axial
and coronal cuts
Disposition - If no diplopia, minimal displacement,
and no muscle entrapment, discharge with
ophthalmology follow up within a week.
Surgery - For enophthalmos, muscle entrapment, or
visual loss.
Management:
Ice packs beginning in clinic/ED and for 48 hrs
will help decrease swelling associated with
injury.
Elevate head of bed (decrease swelling).
If sinuses have been injured, give prophylactic
antibiotics and instruct patient not to blow nose.
Treat nausea/vomiting with antiemetics.
Orbital blowout fracture
Blowout Fractures
Traumatic Eye Injuries
Corneal injuries
Abrasions, lacerations, ulcers
Symptoms:
extreme eye pain, relieved with
lidocaine drops.
Visual acuity usually decreased,
depending on location of injury in
relation to visual axis.
Inflammation leading to corneal
edema can decrease VA.
Diagnosis: fluorescein staining
to see epithelial defect.
Seidel’s test for aqueous
leakage to diagnose laceration.
Corneal Foreign Body
Treatment
Apply topical anesthetic
Remove foreign body with
sterile irrigating solution or
moistened sterile cotton swab
Never use needle
Apply antibiotic ointment
24-hour follow-up is mandatory
Refer if foreign body cannot be
removed
Corneal injuries
Seidel’s test:
Concentrated
fluorescein is dark
orange but turns bright
green under blue light
after dilution.
This indicates aqueous
leakage which is
diluting the green dye.
Topical antibiotics and follow up with
ophthalmologist.
For lacerations, <1 cm, topical antibiotics and
discharge with follow up.
If >1 cm, refer to ophthalmologist to rule out
globe rupture and for possible suture
placement.
Avoid contact lenses
Avoid patching
Management of Corneal
Injury
Penetrating trauma
leads to corneal or
scleral disruption
and extravasation of
intraocular contents.
Can lead to:
Irreversible visual loss
Endophthalmitis -
inflammation of the
intraocular cavities
Ruptured globe
Signs and symptoms:
pain, decreased vision
hyphema
loss of anterior chamber
depth
“tear-drop” pupil which
points toward laceration
severe subconjunctival
hemorrhage completely
encircling the cornea.
Diagnosis: positive
Seidel’s test, clinical
exam.
Ruptured Globe
Ruptured Globe
Management
Stop the examination
Cover with metal eye shield or
styrofoam cup. DO NOT PATCH.
Consult ophthalmology immediately
Do not perform tonometry.
CT head and orbit to evaluate for
concomitant facial/orbital injury.
Tetanus toxoid
Antibiotics: Cefazolin + ciprofloxacin
provides good coverage.
Antiemetics and analgesics decrease risk
of Valsalva or movement which could
increase IOP.
Subconjunctival Hemorrhage
Disruption of conjunctival blood vessel
Etiology
Trauma
Sneezing
Gagging
Valsalva
Will resolve spontaneously within 2 weeks
*If dense, circumferential bloody chemosis is
present, must rule out globe rupture
Traumatic Eye Injuries
Traumatic Eye Injuries
Subconjunctival Hemorrhage
Disruption of conjunctival blood vessel
Etiology
Trauma
Sneezing
Gagging
Valsalva
Will resolve spontaneously within 2 weeks
*If dense, circumferential bloody chemosis is
present, must rule out globe rupture
Traumatic Eye Injuries
Subconjunctival Hemorrhage
Disruption of conjunctival blood vessel
Etiology
Trauma
Sneezing
Gagging
Valsalva
Will resolve spontaneously within 2
weeks
*If dense, circumferential bloody chemosis
is present, must rule out globe rupture
Traumatic Eye Injuries
Conjunctival Abrasion
Superficial abrasions
Treatment: 2-3 days of erythromycin ointment
Ocular foreign body should be excluded
Corneal Abrasion
Tearing, photophobia, blepharospasm, severe
pain
Fluorescein: dye uptake at defect site
Rule out foreign body
Treatment:
Cycloplegic
Topical Tobramycin, Erythromycin, or
Bacitracin/polymyxin drops
Contact lens wearers: Cipro, Ofloxacin, or
Tobramycin drops
Tetanus shot
Ophthalmology consult within 24 hours
Traumatic Eye Injuries
Corneal Abrasion
Tearing, photophobia, blepharospasm, severe
pain
Fluorescein: dye uptake at defect site
Rule out foreign body
Treatment:
Cycloplegic
Topical Tobramycin, Erythromycin, or
Bacitracin/polymyxin drops
Contact lens wearers: Cipro, Ofloxacin, or
Tobramycin drops
Tetanus shot
Ophthalmology consult within 24 hours
Traumatic Eye Injuries
Conjunctival Foreign Bodies
Lid eversion
Remove with a moistened sterile swab
Traumatic Eye Injuries
Traumatic Eye Injuries
Conjunctival Foreign Bodies
Lid eversion
Remove with a moistened sterile swab
Corneal Foreign Bodies
May be removed with fine needle tip, eye
spud, or eye burr after topical anesthetic
applied
Then treat as a corneal abrasion
Deep corneal stoma FB or those in central
visual axis require ophtho consult for removal
Rust rings can be removed with eye burr, but
not urgent
Optho follow up in 24 hours for residual rust
or deep stromal involvement
Traumatic Eye Injuries
Corneal Foreign Bodies
May be removed with fine needle tip, eye
spud, or eye burr after topical anesthetic
applied
Then treat as a corneal abrasion
Deep corneal stoma FB or those in central
visual axis require ophtho consult for removal
Rust rings can be removed with eye burr, but
not urgent
Optho follow up in 24 hours for residual rust
or deep stromal involvement
Traumatic Eye Injuries
Corneal Foreign Bodies
May be removed with fine needle tip, eye
spud, or eye burr after topical anesthetic
applied
Then treat as a corneal abrasion
Deep corneal stoma FB or those in central
visual axis require ophtho consult for removal
Rust rings can be removed with eye burr, but
not urgent
Optho follow up in 24 hours for residual rust
or deep stromal involvement
Traumatic Eye Injuries
Lid Lacerations
Must exclude damage to eye and nasolacrimal
system
Fluorescein staining in the tear layer that appear
in the adjacent lac confirm nasolacrimal
involvement
Most require ophtho consult
Traumatic Eye Injuries
Lid Lacerations
Must exclude damage to eye and nasolacrimal
system
Fluorescein staining in the tear layer that appear
in the adjacent lac confirm nasolacrimal
involvement
Most require ophtho consult
Traumatic Eye Injuries
Traumatic Eye Injuries
Blunt Trauma
Immediately assess integrity of globe and visual
acuity
Eval depth of anterior chamber, pupil size,
monocular blindness ruptured globe
Traumatic Eye Injuries
Hyphema
Blood in the anterior chamber
Spontaneous or post-trauma
Treatment:
Place the pt upright to allow
inferior settling of blood
Exclude ruptured globe
Dilate the pupil with atropine
Measure intraocular pressure – if >
30 mmHg apply topical Timolol
Emergent Optho eval
Traumatic Eye Injuries
Blowout Fractures
Inferior and medial wall most at risk
Evaluate for
inferior rectus entrapment (diplopia on upward
gaze)
infraorbital nerve paresthesia
subcutaneous emphysema (when blowing the
nose)
Orbital cut CT scan
Treatment: rule out ocular trauma and give
oral Keflex
Isolated blowout fracture – ophtho eval in 3 –
10 days
Traumatic Eye Injuries
Penetrating Trauma/Ruptured Globe
Severe subconjunctival hemorrhage
Shallow or deep anterior chamber in one eye
Hyphema
Tear-drop shaped pupil
Traumatic Eye Injuries
Penetrating Trauma/Ruptured Globe
Seidel’s test
Fluourescein
streaming
Traumatic Eye Injuries
Traumatic Eye Injuries
Penetrating Trauma/Ruptured Globe
Penetrating Trauma/Ruptured Globe
If a globe injury is suspected:
Don’t manipulate the eye any more
…Step away from the eye
Place the pt upright
Protective eye shield
Administer IV cephazolin and antiemetic
Tetanus
Traumatic Eye Injuries
Penetrating Trauma/Ruptured Globe
Orbital CT
If intraocular foreign body suspected
Call Ophtho right away
Traumatic Eye Injuries
Chemical Ocular Injury
Acid or alkali – treat the same
Immediately flush (at the scene)
Continue to flush until pH is normal (7.0)
Check with urine dipstick
Recheck pH after sweeping the fornices for
retained particles
Measure IOP
Traumatic Eye Injuries
Chemical Ocular Injury
Treatment:
Cycloplegic
Erythromycin ointment
Narcotic pain meds
Tetanus
Immediate ophtho eval if not completely normal
after initial measures
Traumatic Eye Injuries
What Do You Do?
1. Stabilize hook
2. Brief exam to document
visual acuity, pupillary
responses, visual fields
3. Protect eye from further
damage
4. Tetanus, IV Abx
5. Pain control, antiemetics
6. Send to Ophtho!
Crazy Glue!
Traumatic Eye Injuries
Quick Snappers
{
Hordeolum (Sty)
Chalazion
Chemosis
Subconjunctival
Hemorrhage
Pinguecula
Pterygium
Herpes Simplex Kerititis
