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Ocular emergencies
MEDICINE AND OTHER SPECIALTIES
Ocular emergencies
Key points
LZ Heng
C
Identification of ‘red flags’ is important to recognize ophthalmic emergencies requiring immediate referral and intervention to prevent visual loss
C
A systematic approach to the history and examination usually identifies the underlying differential diagnosis
C
Evaluation of appropriate signs should lead clinicians to involve an ophthalmologist as soon as possible
Robin D Hamilton
Abstract Ophthalmic emergencies vary widely in their nature, speed of onset and associated pathology. They can be life-threatening or sightthreatening. The medical practitioner needs to be able to identify when an ocular pathology requires intervention immediately or within 24 hours, or can be referred to outpatients. This chapter discusses the presentation, basic investigations and treatment that can save vision and, on occasions, life.
contact lens wear. With trauma, determine the involvement of foreign objects, the types of object (e.g. metallic, vegetation) and the mechanism of injury. This is because small, sharp and high-velocity objects from hammering metal or using of a grinder often lead to penetrating injuries.
Keywords Giant cell arteritis; glaucoma; globe rupture; keratitis; MRCP; ophthalmic emergency; papilloedema
Clinical examination Examination ideally involves visual assessment and slit-lamp biomicroscopy. In particular, the following must be ascertained: assessment of vision using a Snellen chart at 6 m pupil examination to determine the afferent and efferent pathways: size of the pupils reactivity of the pupils any relative afferent pupillary defect (RAPD) integrity of the eyelids, including any lumps, bumps or lacerations (partial or full thickness, involvement of the canaliculi) in cases of trauma periorbital redness and swelling; if present, temperature measurements must be documented eye redness: generalized or localized corneal ulcers and haze results of fluorescein staining and examination under a blue light to help determine integrity of the corneal epithelium. If full-thickness corneal injury is present after trauma, aqueous humour may be seen to leak (Seidel test) presence of blood (hyphema) or pus (hypopyon) in the anterior chamber of the eye fundal examination with cycloplegic eye drops such as tropicamide 1% or cyclopentolate 0.5% or 1%.
Introduction Ophthalmic emergency services have seen an escalating number of attendances over recent years. It is important for medical practitioners to recognize emergency eye conditions as delays in treatment can cause vision impairment. Ophthalmic emergencies include traumatic injuries (e.g. chemical injury, penetrating or non-penetrating eye injury) or non-traumatic conditions, such as acute glaucoma, contact lens keratitis and retinal detachment. Other ophthalmic emergencies, such as giant cell arteritis (GCA) and papilloedema, can have systemic implications. These emergencies must be detected, immediately treated and, if necessary, referred to an ophthalmologist. Table 1 gives an overall view of the time factors involved in referral to an ophthalmologist.1
Clinical approach to a patient presenting with an eye problem Taking an ophthalmic history The patient’s history is paramount to the diagnosis. In general, the following areas act as basic signposts in ophthalmic history-taking: onset and duration of symptoms e including previous trauma previous ocular history e e.g. cataract surgery, previous inflammation red eye (Table 2) pain, photophobia and decreased vision
Management Management depends on the differential diagnosis. All patients presenting with acute ocular emergencies must be referred to a specialist at some point, depending on urgency (see Table 1). The following section highlights ‘red flag’ signs associated with diagnosis and specific emergency management.
LZ Heng MBBS PhD FRCOphth FHEA is a registrar at Bristol Eye Hospital, an Honorary Clinical Lecturer at Institute of Ophthalmology, University College London and an Honorary Fellow in the medical retina department, Moorfields Eye Hospital, London, UK. Competing interests: none declared.
Specific emergencies
Robin D Hamilton MB BS DM(dist) FRCOphth is Consultant Ophthalmic Surgeon at Moorfields Eye Hospital NHS Foundation Trust, and Honorary Senior Lecturer at the National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at Moorfields Eye Hospital, London, UK. Competing interests: none declared.
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Acute glaucoma Patients (often middle-aged women with hypermetropia) usually present with painful red eye, blurred vision, nausea and vomiting. Clinical examination may reveal (Figure 1):
754
Ó 2018 Published by Elsevier Ltd.
MEDICINE AND OTHER SPECIALTIES
IMMEDIATE Contact on-call ophthalmologist at your local hospital
• Acute glaucoma • Chemical burn (check • • • • • • •
• •
•
•
Corneal laceration Globe perforation Intraocular FB Hypopyon (pus in anterior chamber) Iris prolapse (cover with an eye shield) Orbital cellulitis Central retinal artery occlusion (<8 hours onset)/acute <24 hour visual loss Giant cell arteritis with visual disturbance Sudden unexplained severe visual loss of <12 hours Painful eye in postoperative intraocular surgery (<2 months postoperativelty Acute IIIrd cranial nerve palsy if pupil involvement or pain
WITHIN 1 WEEK
WITHIN 24 HOURS Make appointment via local eye clinic
• • • •
• • • •
• • • • • • • • • •
NOT AN EMERGENCY Routine referral if unable to manage in practice
post referral letter to eye clinic
Arc eye Corneal abrasion Corneal FB Sub-tarsal FB (only if unsure of diagnosis or cannot manage appropriately) Blunt trauma Contact lens-related problems Corneal graft patients Corneal ulcers or painful/corneal opacities Hyphema Iritis Lid laceration Orbital fractures Painful eye Retinal detachment/tear Vitreous haemorrhage Sudden loss of vision of >12 hours Neonatal conjunctivitis White pupil in children/lack of red
• Sudden/recent onset of diplopia • Sudden/recent onset of distortion of vision or suspected wet AMD • Entropion that is painful • HZO with eye involvement • Episcleritis (if cannot manage appropriately) • Scleritis • Posterior vitreous detachment • Bell’s palsy • Optic neuritis • Severe infective conjunctivitis • Vein occlusions • Proliferative diabetic retinopathy
• Allergic conjunctivitis • Mild – moderate conjunctivitis • Blepharitis • Chalazion • Dry eyes • Ectropion • Watery eye • Subconjunctival haemorrhage retinopathy • Squint – gradual onset or long-standing • Cataract
AMD, age-related macular degeneration; fb, foreign body; HZO, herpes zoster ophthalmicus. Table 1
Causes of a red eye Cause
Conjunctival injection
Unilateral or bilateral
Pain
Photophobia
Vision
Pupil
Intraocular pressure
Conjunctivitis
Diffuse
Gritty
Normal
Normal
Diffuse Circumcorneal Diffuse
Occasionally with adenovirus Yes Yes Mild
Normal
Keratitis Anterior uveitis Acute glaucoma
Bilateral (often unilateral initially) Unilateral Unilateral Unilateral
Reduced Reduced Reduced
Normal Constricted Mid-dilated
Normal Normal or raised Raised
Gritty Painful Severe pain
Table 2
a decrease in visual acuity generalized red eye a hazy cornea a mid-dilated pupil raised intraocular pressure.
MEDICINE 46:12
Patients must immediately be referred to an ophthalmologist as they can very rapidly lose their vision. If there are no contraindications, they must be started on anti-glaucoma medication. This includes intravenous acetazolamide, prostaglandin analogues, badrenoceptor blockers (timolol 0.25%), iopidine or pilocarpine
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MEDICINE AND OTHER SPECIALTIES
With epithelial dendritic ulcers (Figure 2b), patients are started on aciclovir or ganciclovir ointment five times a day. If there is significant inflammation and decreased vision, a dilated fundal examination is warranted to rule out acute retinal necrosis. Uveitis Patients typically present with generalized redness and pain. The history must be taken to rule out a history of systemic inflammatory conditions such as inflammatory bowel disease, ankylosing spondylitis, Behc‚et’s disease, sarcoidosis and infectious diseases such as syphilis or herpes. Uveitis can be divided into anterior and posterior (vitritis, retinal vasculitis, retinitis, choroiditis). Panuveitis affects both the anterior and posterior segments. An urgent referral should be made to the ophthalmological services for corticosteroid eye drop treatment. Blood tests are taken to rule out underlying medical conditions.
Figure 1 Acute glaucoma. Typical signs are a red eye, hazy cornea, shallow anterior chamber and mid-dilated pupil.
Infections Ocular emergencies can be the result of infections such as orbital cellulitis, endophthalmitis and dacryocystitis. Orbital cellulitis: patients may be elderly and/or immunocompromized. They can present with fever, a single or bilateral swollen red eyes, diplopia and loss of colour vision or vision. Examination can reveal: RAPD loss of colour vision measured using an Ishihara chart decrease in vision swollen red eye conjunctival injection compromized ocular movements. An urgent computed tomography (CT) scan is required to look for a source of infection, particularly sinus involvement, and the extent of peri-orbital or orbital cellulitis and abscesses. Temperature and vital observations are monitored frequently. Patients should be started on intravenous antibiotics in accordance with the local hospital trust’s protocols. Endophthalmitis: this is an ocular emergency, usually occurring after a procedure such as ocular surgery or intravitreal injection. Endogenous endophthalmitis is rare but can present in immunocompromized patients with systemic infection. Patients present with a painful red eye with loss of vision, usually 2e5 days after the procedure, but it can happen at any time. Clinical examination can reveal: red eye decrease in vision hypopyon anterior chamber inflammation and fibrin vitreous haze retinal necrosis (rarely). Patients must be immediately referred to the ocular emergency services,2 where aqueous and vitreous samples should be taken and an intravitreal injection of antibiotics (ceftazidime, vancomycin) given. Hourly levofloxacin eye drops are instilled for 24 hours and tapered upon review.
Figure 2 Corneal ulcers. (a) A contact lens ulcer with a central white ulcer and adjacent conjunctival hyperaemia. (b) A dendritic ulcer in herpes simplex. Note the clear dendritic fluorescence under blue light.
2%. When the corneal haziness clears, a laser peripheral iridotomy or laser iridoplasty can be attempted by an ophthalmologist. Keratitis The patient typically presents with a painful red eye. There may be a history of contact lens wear or previous herpetic keratitis or cold sores. In contact lens-related keratitis, the differential diagnosis includes bacterial keratitis (Figure 2a) and acanthamoebic keratitis. A corneal scrape must be performed and sent for culture. Levofloxacin eye drops are given on a hourly basis day and night, and the patient reviewed the following day.
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Retinal detachment Patient usually presents with a sudden onset of ‘flashes and floaters’ or a curtain covering the visual fields. Associated risks
756
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MEDICINE AND OTHER SPECIALTIES
possibly segmental blood flow (box-carring) in the blood vessels the presence of emboli e calcific or cholesterol. CRAO is an ocular emergency because of the short window (usually <6 hours) for efficacious treatment. Work-up includes blood pressure, blood samples for glucose, full blood count, erythrocyte sedimentation rate, C-reactive protein, urea and electrolytes, and, in patients <50 years of age, a coagulation work-up. GCA must be ruled out in elderly patients. Conservative treatment such as ocular massage and rebreathing into can be attempted. Referral to a physician is important for carotid ultrasonography, an echocardiogram and a 24-hour electrocardiogram to look for embolic causes.
include pathological myopia (> 6 D), a previous ocular history of tears or detachment and a family history of retinal detachment. Clinical examination can reveal: decreased visual acuity, RAPD and possible visual field defects retina tear(s) or hole(s) with pigmented vitreous cells (tobacco dust) macular ‘on’/‘off’ retinal detachment. A macular ‘on’ detachment warrants an immediate ophthalmic referral for retinal detachment surgery. Central retinal artery occlusion (CRAO) Patients usually present with a painless loss of vision in one eye. Examination reveal the following: decreased vision RAPD retinal whitening with a cherry red spot (Figure 3)
Optic neuropathies Arteritic optic neuropathy secondary to giant cell arteritis: GCA must be suspected in patients with a history of polymyalgia rheumatica who present with the following: Temporal arteritis occurs in patients >50 years of age and has the following classical presentation: temporal headaches scalp tenderness jaw claudication. Typical clinical signs include: decreased visual acuity prominent and tender temporal arteries that may be pulseless swollen optic nerves ocular nerve palsies CRAO or branch retinal artery occlusion. Raised inflammatory markers and thrombocytosis are indicators of GCA. The gold standard for diagnosis is a temporal artery biopsy, looking for granulomatous changes in the arterial wall. Newer diagnostic tools include ultrasonography of
Figure 3 Cherry red spot and pale retina in CRAO.
Figure 4 Papilloedema. Bilateral disc swelling with indistinct disc margins, a lack of the disc cup, dilated capillaries, haemorrhages and dilated veins are seen.
MEDICINE 46:12
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MEDICINE AND OTHER SPECIALTIES
the temporal artery looking for hypoechogenic halo signs. High-dose corticosteroids must be started if there is a high index of suspicion of GCA, and a rheumatological referral made.
is more likely to be the result of a posterior communicating artery aneurysm if there is pain. It is more likely caused by a compression if the pupil is dilated. Other symptoms include diplopia and lid droop. Once examination, there is ptosis and the eye points down and out (see Figure 5).
Papilloedema: this commonly presents with severe headaches and focal neurological signs. Clinical examination shows bilateral optic nerve swelling (Figure 4). Urgent CT of the head must be arranged, and a neurological referral made, as it usually indicates an increased intracranial pressure. Sinus thrombosis must be ruled out before a diagnosis of idiopathic intracranial hypertension can be made.
Trauma Mechanical injury to the globe: blunt or sharp high-velocity trauma can cause ocular damage as a result of globe rupture, eyelid laceration, traumatic optic neuropathy, orbital compartment syndrome or orbital floor fractures. Ocular injury from high-velocity trauma or metallic objects should be treated as a penetrating injury. Penetrating eye injury from a very small object at high speed is often detected only as a small corneal defect on fluorescein staining. Patients must be
Acute IIIrd cranial nerve palsy: an acute IIIrd nerve palsy associated with headache is a medical emergency. The aetiology
Pathway for timing of referral for investigation and treatment Common ocular emergencies Non-traumatic
Painful red eye
Traumatic NO
Loss of vision
• Globe rupture • Lid laceration *Rule out orbital compartment syndrome
Chemical
Yes
Yes
pH < 7.2 or > 7.8 Contact lens wearer Yes Contact lens keratits
Copious irrigation/then urgent referral to HES
NO Retina detachment
Fixed, middilated pupil Yes
Acute Immediate referral to glaucoma HES
Immediate referral to HES
Floaters
NO Fever + periobital tissue swelling and erythema Yes
Immediate referral to Orbital HES cellulitis
Swollen optic nerves
Yes
NO
Immediate referral to HES
AMD CSR
Bilateral Yes
NO
Referral to Papilloedema HES within 2 weeks
Prior ocular procedure/surgery Yes
Admit for IV Endophthalmitis antibiotics and get urgent HES review
NO Uveitis
Immediate Urgent referral HES referral for treatment for tap and inject intravitreal antibiotics
NO Temporal tenderness
Urgent CT/MRI Yes and CTV/MRV, neurology Suspect referral, HES GCA review
NO Optic neuropathies • Optic neuritis • NAION • Toxic • Tumour-related
markers, start high-dose steroids, rheumatology referral, HES referral Urgent HES referral
AMD, age-related macular degeneration; CSR, central serous retinopathy; CTV, CT venography; GCA, giant cell arteritis; HES, hospital eye services; MRV, magnetic resonance venography; NAION; Non-arteritic anterior ischaemic optic neuropathy. Figure 5
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MEDICINE AND OTHER SPECIALTIES
treated immediately to prevent endophthalmitis, retina detachments and subsequent loss of vision. Blunt orbital trauma can cause fractures within the orbital cavity. The weakest bones are in the orbital floor, and the orbital contents can extrude into the maxillary sinus. Fluid or blood levels are often seen within the sinus on anteroposterior X-ray. As the orbital contents fall into the sinus, the globe can retract into the orbital cavity (enophthalmos). The inferior rectus muscle can also become trapped, leading to reduced upgaze and diplopia (double vision) either in the primary gaze or on elevation. Such cases are co-managed by ophthalmologists and maxillofacial surgeons, although surgical intervention is not always necessary. In all cases of ocular trauma with suspected globe rupture or orbital floor fracture, the patient should be referred to an ophthalmologist. In the emergency department setting, it is imperative to rule out orbital compartment syndrome, which includes the following signs: proptosis a hard eye or raised intraocular pressure RAPD decreased vision. An immediate lateral canthotomy is required, preferably before the immediate referral to an ophthalmologist, as visual loss can occur within minutes if left untreated.
Chemical injury: topical anaesthetic drops such as proxymetacaine can help to relieve pain and allow ocular examination and irrigation. Immediate eye irrigation with normal sodium chloride or Ringer’s lactate solution should be initiated until the pH is consistently neutral (7.0). The pH should be frequently tested after irrigation to ensure it is remaining stable. After eye irrigation, the patient should be urgently seen in the eye department. Treatment involves administering preservativefree corticosteroid eye drops on an hourly basis, preservative-free topical antibiotics 6 hourly, cycloplegic drops three times a day, and topical ascorbic acid drops hourly or high-dose oral vitamin C (g daily), with continuing close observation. A KEY REFERENCES 1 https://www.rcophth.ac.uk/wpcontent/uploads/2014/12/2013_ PROF_203_EmergencyEyeCare.pdf. 2 Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995; 113: 1479e96.
TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here. What is the best management option? A Observe and do nothing B Refer back to GP for low-dose steroids C Immediately high-dose steroids D Intravitreal ranibizumab E Refer to neurosurgery.
Question 1 A 65-year-old woman presented with a 2-hour history of sudden painless loss of vision in her left eye. She had a history of transient ischaemic attacks and a 60% blockage of her carotid arteries on ultrasound. On clinical examination, she was found to have 6/60 vision in her left eye, and 6/6 vision in the right. There was a left relative afferent pupillary defect. Anterior segment examination of her eye was unremarkable. Fundal examination showed a pale retina with a red foveal avascular zone.
Question 3 A 22-year-old man presented with a 2-week history of severe headache, vomiting and diplopia. Clinical examination showed bilateral optic nerve swelling.
What is the most appropriate next step in her management? A Ocular massage and rebreathing B Referral to a neurologist. C Intravenous corticosteroids D An urgent CT of the head E Intravenous antibiotics
Investigation Visual field testing showed a bi-temporal hemianopia What is the most appropriate next step in management? A Observation B Routine CT or MRI of the brain C Urgent CT or MRI of the brain D Routine administration of hydrocortisone intravenously E Ophthalmology referral
Question 2 An 80-year-old woman presented with a 2-week history of leftsided headache and a 1-day history of loss of vision. She had a previous history of polymyalgia rheumatica. Investigation Temporal artery biopsy histology demonstrated granulomatous lesions in the walls of the artery.
MEDICINE 46:12
759
Ó 2018 Published by Elsevier Ltd.
Ocular emergencies
Key points
LZ Heng
C
Identification of ‘red flags’ is important to recognize ophthalmic emergencies requiring immediate referral and intervention to prevent visual loss
C
A systematic approach to the history and examination usually identifies the underlying differential diagnosis
C
Evaluation of appropriate signs should lead clinicians to involve an ophthalmologist as soon as possible
Robin D Hamilton
Abstract Ophthalmic emergencies vary widely in their nature, speed of onset and associated pathology. They can be life-threatening or sightthreatening. The medical practitioner needs to be able to identify when an ocular pathology requires intervention immediately or within 24 hours, or can be referred to outpatients. This chapter discusses the presentation, basic investigations and treatment that can save vision and, on occasions, life.
contact lens wear. With trauma, determine the involvement of foreign objects, the types of object (e.g. metallic, vegetation) and the mechanism of injury. This is because small, sharp and high-velocity objects from hammering metal or using of a grinder often lead to penetrating injuries.
Keywords Giant cell arteritis; glaucoma; globe rupture; keratitis; MRCP; ophthalmic emergency; papilloedema
Clinical examination Examination ideally involves visual assessment and slit-lamp biomicroscopy. In particular, the following must be ascertained: assessment of vision using a Snellen chart at 6 m pupil examination to determine the afferent and efferent pathways: size of the pupils reactivity of the pupils any relative afferent pupillary defect (RAPD) integrity of the eyelids, including any lumps, bumps or lacerations (partial or full thickness, involvement of the canaliculi) in cases of trauma periorbital redness and swelling; if present, temperature measurements must be documented eye redness: generalized or localized corneal ulcers and haze results of fluorescein staining and examination under a blue light to help determine integrity of the corneal epithelium. If full-thickness corneal injury is present after trauma, aqueous humour may be seen to leak (Seidel test) presence of blood (hyphema) or pus (hypopyon) in the anterior chamber of the eye fundal examination with cycloplegic eye drops such as tropicamide 1% or cyclopentolate 0.5% or 1%.
Introduction Ophthalmic emergency services have seen an escalating number of attendances over recent years. It is important for medical practitioners to recognize emergency eye conditions as delays in treatment can cause vision impairment. Ophthalmic emergencies include traumatic injuries (e.g. chemical injury, penetrating or non-penetrating eye injury) or non-traumatic conditions, such as acute glaucoma, contact lens keratitis and retinal detachment. Other ophthalmic emergencies, such as giant cell arteritis (GCA) and papilloedema, can have systemic implications. These emergencies must be detected, immediately treated and, if necessary, referred to an ophthalmologist. Table 1 gives an overall view of the time factors involved in referral to an ophthalmologist.1
Clinical approach to a patient presenting with an eye problem Taking an ophthalmic history The patient’s history is paramount to the diagnosis. In general, the following areas act as basic signposts in ophthalmic history-taking: onset and duration of symptoms e including previous trauma previous ocular history e e.g. cataract surgery, previous inflammation red eye (Table 2) pain, photophobia and decreased vision
Management Management depends on the differential diagnosis. All patients presenting with acute ocular emergencies must be referred to a specialist at some point, depending on urgency (see Table 1). The following section highlights ‘red flag’ signs associated with diagnosis and specific emergency management.
LZ Heng MBBS PhD FRCOphth FHEA is a registrar at Bristol Eye Hospital, an Honorary Clinical Lecturer at Institute of Ophthalmology, University College London and an Honorary Fellow in the medical retina department, Moorfields Eye Hospital, London, UK. Competing interests: none declared.
Specific emergencies
Robin D Hamilton MB BS DM(dist) FRCOphth is Consultant Ophthalmic Surgeon at Moorfields Eye Hospital NHS Foundation Trust, and Honorary Senior Lecturer at the National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at Moorfields Eye Hospital, London, UK. Competing interests: none declared.
MEDICINE 46:12
Acute glaucoma Patients (often middle-aged women with hypermetropia) usually present with painful red eye, blurred vision, nausea and vomiting. Clinical examination may reveal (Figure 1):
754
Ó 2018 Published by Elsevier Ltd.
MEDICINE AND OTHER SPECIALTIES
IMMEDIATE Contact on-call ophthalmologist at your local hospital
• Acute glaucoma • Chemical burn (check • • • • • • •
• •
•
•
Corneal laceration Globe perforation Intraocular FB Hypopyon (pus in anterior chamber) Iris prolapse (cover with an eye shield) Orbital cellulitis Central retinal artery occlusion (<8 hours onset)/acute <24 hour visual loss Giant cell arteritis with visual disturbance Sudden unexplained severe visual loss of <12 hours Painful eye in postoperative intraocular surgery (<2 months postoperativelty Acute IIIrd cranial nerve palsy if pupil involvement or pain
WITHIN 1 WEEK
WITHIN 24 HOURS Make appointment via local eye clinic
• • • •
• • • •
• • • • • • • • • •
NOT AN EMERGENCY Routine referral if unable to manage in practice
post referral letter to eye clinic
Arc eye Corneal abrasion Corneal FB Sub-tarsal FB (only if unsure of diagnosis or cannot manage appropriately) Blunt trauma Contact lens-related problems Corneal graft patients Corneal ulcers or painful/corneal opacities Hyphema Iritis Lid laceration Orbital fractures Painful eye Retinal detachment/tear Vitreous haemorrhage Sudden loss of vision of >12 hours Neonatal conjunctivitis White pupil in children/lack of red
• Sudden/recent onset of diplopia • Sudden/recent onset of distortion of vision or suspected wet AMD • Entropion that is painful • HZO with eye involvement • Episcleritis (if cannot manage appropriately) • Scleritis • Posterior vitreous detachment • Bell’s palsy • Optic neuritis • Severe infective conjunctivitis • Vein occlusions • Proliferative diabetic retinopathy
• Allergic conjunctivitis • Mild – moderate conjunctivitis • Blepharitis • Chalazion • Dry eyes • Ectropion • Watery eye • Subconjunctival haemorrhage retinopathy • Squint – gradual onset or long-standing • Cataract
AMD, age-related macular degeneration; fb, foreign body; HZO, herpes zoster ophthalmicus. Table 1
Causes of a red eye Cause
Conjunctival injection
Unilateral or bilateral
Pain
Photophobia
Vision
Pupil
Intraocular pressure
Conjunctivitis
Diffuse
Gritty
Normal
Normal
Diffuse Circumcorneal Diffuse
Occasionally with adenovirus Yes Yes Mild
Normal
Keratitis Anterior uveitis Acute glaucoma
Bilateral (often unilateral initially) Unilateral Unilateral Unilateral
Reduced Reduced Reduced
Normal Constricted Mid-dilated
Normal Normal or raised Raised
Gritty Painful Severe pain
Table 2
a decrease in visual acuity generalized red eye a hazy cornea a mid-dilated pupil raised intraocular pressure.
MEDICINE 46:12
Patients must immediately be referred to an ophthalmologist as they can very rapidly lose their vision. If there are no contraindications, they must be started on anti-glaucoma medication. This includes intravenous acetazolamide, prostaglandin analogues, badrenoceptor blockers (timolol 0.25%), iopidine or pilocarpine
755
Ó 2018 Published by Elsevier Ltd.
MEDICINE AND OTHER SPECIALTIES
With epithelial dendritic ulcers (Figure 2b), patients are started on aciclovir or ganciclovir ointment five times a day. If there is significant inflammation and decreased vision, a dilated fundal examination is warranted to rule out acute retinal necrosis. Uveitis Patients typically present with generalized redness and pain. The history must be taken to rule out a history of systemic inflammatory conditions such as inflammatory bowel disease, ankylosing spondylitis, Behc‚et’s disease, sarcoidosis and infectious diseases such as syphilis or herpes. Uveitis can be divided into anterior and posterior (vitritis, retinal vasculitis, retinitis, choroiditis). Panuveitis affects both the anterior and posterior segments. An urgent referral should be made to the ophthalmological services for corticosteroid eye drop treatment. Blood tests are taken to rule out underlying medical conditions.
Figure 1 Acute glaucoma. Typical signs are a red eye, hazy cornea, shallow anterior chamber and mid-dilated pupil.
Infections Ocular emergencies can be the result of infections such as orbital cellulitis, endophthalmitis and dacryocystitis. Orbital cellulitis: patients may be elderly and/or immunocompromized. They can present with fever, a single or bilateral swollen red eyes, diplopia and loss of colour vision or vision. Examination can reveal: RAPD loss of colour vision measured using an Ishihara chart decrease in vision swollen red eye conjunctival injection compromized ocular movements. An urgent computed tomography (CT) scan is required to look for a source of infection, particularly sinus involvement, and the extent of peri-orbital or orbital cellulitis and abscesses. Temperature and vital observations are monitored frequently. Patients should be started on intravenous antibiotics in accordance with the local hospital trust’s protocols. Endophthalmitis: this is an ocular emergency, usually occurring after a procedure such as ocular surgery or intravitreal injection. Endogenous endophthalmitis is rare but can present in immunocompromized patients with systemic infection. Patients present with a painful red eye with loss of vision, usually 2e5 days after the procedure, but it can happen at any time. Clinical examination can reveal: red eye decrease in vision hypopyon anterior chamber inflammation and fibrin vitreous haze retinal necrosis (rarely). Patients must be immediately referred to the ocular emergency services,2 where aqueous and vitreous samples should be taken and an intravitreal injection of antibiotics (ceftazidime, vancomycin) given. Hourly levofloxacin eye drops are instilled for 24 hours and tapered upon review.
Figure 2 Corneal ulcers. (a) A contact lens ulcer with a central white ulcer and adjacent conjunctival hyperaemia. (b) A dendritic ulcer in herpes simplex. Note the clear dendritic fluorescence under blue light.
2%. When the corneal haziness clears, a laser peripheral iridotomy or laser iridoplasty can be attempted by an ophthalmologist. Keratitis The patient typically presents with a painful red eye. There may be a history of contact lens wear or previous herpetic keratitis or cold sores. In contact lens-related keratitis, the differential diagnosis includes bacterial keratitis (Figure 2a) and acanthamoebic keratitis. A corneal scrape must be performed and sent for culture. Levofloxacin eye drops are given on a hourly basis day and night, and the patient reviewed the following day.
MEDICINE 46:12
Retinal detachment Patient usually presents with a sudden onset of ‘flashes and floaters’ or a curtain covering the visual fields. Associated risks
756
Ó 2018 Published by Elsevier Ltd.
MEDICINE AND OTHER SPECIALTIES
possibly segmental blood flow (box-carring) in the blood vessels the presence of emboli e calcific or cholesterol. CRAO is an ocular emergency because of the short window (usually <6 hours) for efficacious treatment. Work-up includes blood pressure, blood samples for glucose, full blood count, erythrocyte sedimentation rate, C-reactive protein, urea and electrolytes, and, in patients <50 years of age, a coagulation work-up. GCA must be ruled out in elderly patients. Conservative treatment such as ocular massage and rebreathing into can be attempted. Referral to a physician is important for carotid ultrasonography, an echocardiogram and a 24-hour electrocardiogram to look for embolic causes.
include pathological myopia (> 6 D), a previous ocular history of tears or detachment and a family history of retinal detachment. Clinical examination can reveal: decreased visual acuity, RAPD and possible visual field defects retina tear(s) or hole(s) with pigmented vitreous cells (tobacco dust) macular ‘on’/‘off’ retinal detachment. A macular ‘on’ detachment warrants an immediate ophthalmic referral for retinal detachment surgery. Central retinal artery occlusion (CRAO) Patients usually present with a painless loss of vision in one eye. Examination reveal the following: decreased vision RAPD retinal whitening with a cherry red spot (Figure 3)
Optic neuropathies Arteritic optic neuropathy secondary to giant cell arteritis: GCA must be suspected in patients with a history of polymyalgia rheumatica who present with the following: Temporal arteritis occurs in patients >50 years of age and has the following classical presentation: temporal headaches scalp tenderness jaw claudication. Typical clinical signs include: decreased visual acuity prominent and tender temporal arteries that may be pulseless swollen optic nerves ocular nerve palsies CRAO or branch retinal artery occlusion. Raised inflammatory markers and thrombocytosis are indicators of GCA. The gold standard for diagnosis is a temporal artery biopsy, looking for granulomatous changes in the arterial wall. Newer diagnostic tools include ultrasonography of
Figure 3 Cherry red spot and pale retina in CRAO.
Figure 4 Papilloedema. Bilateral disc swelling with indistinct disc margins, a lack of the disc cup, dilated capillaries, haemorrhages and dilated veins are seen.
MEDICINE 46:12
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Ó 2018 Published by Elsevier Ltd.
MEDICINE AND OTHER SPECIALTIES
the temporal artery looking for hypoechogenic halo signs. High-dose corticosteroids must be started if there is a high index of suspicion of GCA, and a rheumatological referral made.
is more likely to be the result of a posterior communicating artery aneurysm if there is pain. It is more likely caused by a compression if the pupil is dilated. Other symptoms include diplopia and lid droop. Once examination, there is ptosis and the eye points down and out (see Figure 5).
Papilloedema: this commonly presents with severe headaches and focal neurological signs. Clinical examination shows bilateral optic nerve swelling (Figure 4). Urgent CT of the head must be arranged, and a neurological referral made, as it usually indicates an increased intracranial pressure. Sinus thrombosis must be ruled out before a diagnosis of idiopathic intracranial hypertension can be made.
Trauma Mechanical injury to the globe: blunt or sharp high-velocity trauma can cause ocular damage as a result of globe rupture, eyelid laceration, traumatic optic neuropathy, orbital compartment syndrome or orbital floor fractures. Ocular injury from high-velocity trauma or metallic objects should be treated as a penetrating injury. Penetrating eye injury from a very small object at high speed is often detected only as a small corneal defect on fluorescein staining. Patients must be
Acute IIIrd cranial nerve palsy: an acute IIIrd nerve palsy associated with headache is a medical emergency. The aetiology
Pathway for timing of referral for investigation and treatment Common ocular emergencies Non-traumatic
Painful red eye
Traumatic NO
Loss of vision
• Globe rupture • Lid laceration *Rule out orbital compartment syndrome
Chemical
Yes
Yes
pH < 7.2 or > 7.8 Contact lens wearer Yes Contact lens keratits
Copious irrigation/then urgent referral to HES
NO Retina detachment
Fixed, middilated pupil Yes
Acute Immediate referral to glaucoma HES
Immediate referral to HES
Floaters
NO Fever + periobital tissue swelling and erythema Yes
Immediate referral to Orbital HES cellulitis
Swollen optic nerves
Yes
NO
Immediate referral to HES
AMD CSR
Bilateral Yes
NO
Referral to Papilloedema HES within 2 weeks
Prior ocular procedure/surgery Yes
Admit for IV Endophthalmitis antibiotics and get urgent HES review
NO Uveitis
Immediate Urgent referral HES referral for treatment for tap and inject intravitreal antibiotics
NO Temporal tenderness
Urgent CT/MRI Yes and CTV/MRV, neurology Suspect referral, HES GCA review
NO Optic neuropathies • Optic neuritis • NAION • Toxic • Tumour-related
markers, start high-dose steroids, rheumatology referral, HES referral Urgent HES referral
AMD, age-related macular degeneration; CSR, central serous retinopathy; CTV, CT venography; GCA, giant cell arteritis; HES, hospital eye services; MRV, magnetic resonance venography; NAION; Non-arteritic anterior ischaemic optic neuropathy. Figure 5
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MEDICINE AND OTHER SPECIALTIES
treated immediately to prevent endophthalmitis, retina detachments and subsequent loss of vision. Blunt orbital trauma can cause fractures within the orbital cavity. The weakest bones are in the orbital floor, and the orbital contents can extrude into the maxillary sinus. Fluid or blood levels are often seen within the sinus on anteroposterior X-ray. As the orbital contents fall into the sinus, the globe can retract into the orbital cavity (enophthalmos). The inferior rectus muscle can also become trapped, leading to reduced upgaze and diplopia (double vision) either in the primary gaze or on elevation. Such cases are co-managed by ophthalmologists and maxillofacial surgeons, although surgical intervention is not always necessary. In all cases of ocular trauma with suspected globe rupture or orbital floor fracture, the patient should be referred to an ophthalmologist. In the emergency department setting, it is imperative to rule out orbital compartment syndrome, which includes the following signs: proptosis a hard eye or raised intraocular pressure RAPD decreased vision. An immediate lateral canthotomy is required, preferably before the immediate referral to an ophthalmologist, as visual loss can occur within minutes if left untreated.
Chemical injury: topical anaesthetic drops such as proxymetacaine can help to relieve pain and allow ocular examination and irrigation. Immediate eye irrigation with normal sodium chloride or Ringer’s lactate solution should be initiated until the pH is consistently neutral (7.0). The pH should be frequently tested after irrigation to ensure it is remaining stable. After eye irrigation, the patient should be urgently seen in the eye department. Treatment involves administering preservativefree corticosteroid eye drops on an hourly basis, preservative-free topical antibiotics 6 hourly, cycloplegic drops three times a day, and topical ascorbic acid drops hourly or high-dose oral vitamin C (g daily), with continuing close observation. A KEY REFERENCES 1 https://www.rcophth.ac.uk/wpcontent/uploads/2014/12/2013_ PROF_203_EmergencyEyeCare.pdf. 2 Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995; 113: 1479e96.
TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here. What is the best management option? A Observe and do nothing B Refer back to GP for low-dose steroids C Immediately high-dose steroids D Intravitreal ranibizumab E Refer to neurosurgery.
Question 1 A 65-year-old woman presented with a 2-hour history of sudden painless loss of vision in her left eye. She had a history of transient ischaemic attacks and a 60% blockage of her carotid arteries on ultrasound. On clinical examination, she was found to have 6/60 vision in her left eye, and 6/6 vision in the right. There was a left relative afferent pupillary defect. Anterior segment examination of her eye was unremarkable. Fundal examination showed a pale retina with a red foveal avascular zone.
Question 3 A 22-year-old man presented with a 2-week history of severe headache, vomiting and diplopia. Clinical examination showed bilateral optic nerve swelling.
What is the most appropriate next step in her management? A Ocular massage and rebreathing B Referral to a neurologist. C Intravenous corticosteroids D An urgent CT of the head E Intravenous antibiotics
Investigation Visual field testing showed a bi-temporal hemianopia What is the most appropriate next step in management? A Observation B Routine CT or MRI of the brain C Urgent CT or MRI of the brain D Routine administration of hydrocortisone intravenously E Ophthalmology referral
Question 2 An 80-year-old woman presented with a 2-week history of leftsided headache and a 1-day history of loss of vision. She had a previous history of polymyalgia rheumatica. Investigation Temporal artery biopsy histology demonstrated granulomatous lesions in the walls of the artery.
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