OPHTHALMOLOGY EMERGENCY PROTOCOLS
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OCULAR TRAUMA ...... 2 Hyphaema ...... 2 Blow out fracture ...... 3 Retro-orbital Haemorrhage ...... 4 Ruptured Globe/Penetrating trauma ...... 6 LID TRAUMA ...... 7 CHEMICAL INJURY ...... 8 ENDOPHTHALMITIS ...... 10 ORBITAL CELLULITIS ...... 13 ACUTE ANGLE CLOSURE GLAUCOMA ...... 14 CORNEAL ULCER ...... 15 SUDDEN VISUAL LOSS ...... 17 Central retinal artery occlusion (CRAO) ...... 17 Central retinal vein occlusion (CRVO)...... 19 Anterior ischaemic optic neuropathy (AION) ...... 20 Amaurosis fugax ...... 22 Macular haemorrhage ...... 24 Vitreous haemorrhage ...... 25 Retinal detachment ...... 26 Optic neuritis ...... 27 Functional visual loss ...... 28 Migraine ...... 29 RED EYE ...... 30 Foreign body: corneal/conjunctival/subtarsal ...... 30 Corneal abrasion ...... 31 Arc eye ...... 31 Conjunctivitis ...... 32 Iritis ...... 32 Sub-conjunctival haemorrhage ...... 33
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OCULAR TRAUMA
Hyphaema
Following blunt ocular trauma (eg. punch, badminton or football injury) a fluid level of blood (hyphaema) may be visible in the anterior chamber between the cornea and the lens.
Management:
1) Topical Steroid (Maxidex) four times per day 2) Mydriatic (Cyclopentolate 1%) three times per day. 3) Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.
Depending on the mechanism of injury, there might be a corneal abrasion, and this should be managed as per that protocol.
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Blow out fracture
Symptoms:
1) Patient complains of double vision, especially on looking up 2) May have paraesthesia in the distribution of the infra- orbital nerve (check, upper lip, plus teeth and gums)
Signs:
1) Restricted upgaze 2) Enophthalmos (affected eye appears further back in orbit) 3) Inferior orbital fracture on Radiology
Management:
1) Refer to Max-Fax service 2) Referral to Ophthalmology plus Orthoptics - that day or, if out of hours, the following day
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Retro-orbital Haemorrhage
Trauma can rarely cause an arterial bleed behind the orbital septum which can lead to a rapid onset of swelling of the lids and proptosis. Unless dealt with very quickly there is the risk of irreversible blindness.
Symptoms:
1) Pain 2) Decreased vision (hand movements only or worse)
Signs:
1) Tense lid swelling 2) Tense proptosis 3) Decreased eye movements 4) May be difficult to prise the lids apart to examine the globe - if available the insertion of a speculum following instillation of topical anaesthetic may help. 5) Unresponsive pupil
Management:
Requires immediate lateral canthotomy.
1) Infiltration of local anaesthetic into the lateral lower lid 2) Disinsert lower lid at the lateral end by placing sharp scissors into the lower lid and cutting downward and laterally towards the orbit (ensuring that the orbital
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septum is penetrated). There should be a release of the orbital blood which will be under pressure. (video at https://first10em.com/lateral-canthotomy/) 3) Admit 4A
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Ruptured Globe/Penetrating trauma
Usually result of high impact trauma or sharp trauma, eg. falling whilst intoxicated and striking the eye on a table edge or hammer/chisel injuries.
Symptoms:
1) Pain 2) Decreased vision
Signs:
1) Subconjunctival haemorrhage 2) Hyphaema 3) May have obvious corneal or sclera laceration with prolapsing pigmented tissue
Management:
1) Refer Ophthalmology (out of hours - admit to Ward 4A with review the next morning) 2) Eye shield 3) Nurse propped up 4) Chloramphenicol eye drops 4 times per day 5) IV Ciprofloxacin 400mg bd 6) Analgesia 7) Keep nil by mouth from 2am
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LID TRAUMA
• Ask about mechanism of injury. If there is a possibility of an orbital foreign body, arrange CT orbits • Explore depth of wound, check vision and examine ocular surface. If there is a significant ocular injury follow the ocular trauma protocol • Check tetanus status, give booster if necessary • Animal bites require broad spectrum oral antibiotics • Superficial tear to skin o Clean and apply steristrips • Deep laceration o Clean and glue or suture with 6/0 nylon (or similar) o Refer for routine ophthalmology follow-up • Any laceration involving the lid margin, any laceration nasal to the punctum in either the upper or lower lid, or if there is extensive tissue loss or distortion of the anatomy o Apply chloramphenicol ointment o Apply non-stick dressing (such as Gelonet) o Apply pad or gauze, and tape tightly • Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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CHEMICAL INJURY
• Immediate treatment (and neutralisation of pH) o Test pH; o Instill topical anaesthetic (Proxymethacaine,Bupivacaine or Tetracaine), o Insert a speculum o Irrigate with at least 2 L of Normal saline or water through IV giving set (including into the fornices) until normal pH is restored
• Inspection o Evert the lids (if possible), inspect lids and fornices and remove any particulate material with a cotton bud (e.g. lime, cement)
• pH testing o Test pH at the end of irrigation and 5 min after. ▪ If pH neutral/near neutral (compare to other eye if necessary), then begin examination and history taking and initiate further treatment (see below). Recheck pH after 20 mins o If pH abnormal, repeat irrigation cycle with another 2 L until pH normal
• Examination o Record visual acuity and pupil reactions o Look for abnormal whitening of conjunctival vessels adjacent to cornea (limbal ischaemia) o Check for corneal/conjunctival abrasions with fluorescein
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• Further treatment o Topical antibiotics: Preservative free Chloramphenicol eye drops 4 times per day o Topical cycloplegia: Preservative free Cyclopentolate 1% 3 times per day o Topical steroids: Preservative free Dexamethasone 0.1% 4 times per day o Topical lubricants: Preservative free Celluvisc 1% or Xailin gel 6 x a day and Xailin Night ointment at night o Oral analgesia as required o Consider admitting to Ward 4A if severe injury (extensive corneal abrasion and limbal ischaemia) o Review by Ophthalmologist same day or following morning if out of hours
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ENDOPHTHALMITIS
Endophthalmitis is an intraocular bacterial infection following intraocular surgery or intraocular injection.
Extremely rare - incidence of 1 per year in NHS Highland.
Can occur any time from the day after surgery to 2 weeks after surgery (most commonly 3 - 5 days following surgery)
Symptoms:
1. Increasingly severe eye pain
2. Increasingly marked eye redness
3. Rapid and significant decreasing vision (often to hand movements or worse), since the procedure.
There are many conditions that can give pain and redness, eg. post-operative iritis, but endophthalmitis is extremely unlikely without a significant drop in vision. Some patients who receive intravitreal injections have poor vision to start with, so it is worth checking with the patient what the vision was like immediately following the procedure.
Also, vision following vitrectomy is often vague hand movements due to intraocular gas, which lasts for 2 weeks post-operatively - this is normal.
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Signs:
1. Decreased acuity (usually counting fingers or hand movements only)
2. Conjunctival redness
3. Anterior chamber inflammation may give rise to:
a) Visible difference between visibility of the iris and pupil between the two eyes – affected eye hazy.
b) Hypopyon (pus level at bottom of anterior chamber - see photograph below)
c) Poorly reactive pupil
Hazy anterior chamber and hypopyon
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Management:
1) Admit to Ward 4A, Raigmore 2) Intravitreal antibiotics by Ophthalmologist as soon as possible 3) Ofloxacin eye drops hourly 4) Oral Ciprofloxacin 750mg bd 5) Atropine 1% eye drops, 3 times per day 6) Analgesia
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ORBITAL CELLULITIS
Symptoms:
Lid swelling Decreased vision Double vision Feels unwell – often preceding URTI
Signs:
Decreased visual acuity Proptosis Lid swelling Conjunctiva red and chemosed Reduced ocular motility May have afferent pupillary defect Pyrexia
Management:
1) Admit under ENT to Ward 4A if adult (Paediatric Ward if a child) for Senior ENT assessment 2) Ophthalmic assessment - visual acuity, colour vision, pupil reactions, ocular motility 3) IV access 4) FBC, U&Es, PV, CRP and blood culture 5) IV antibiotics – Cefotaxime and Flucloxacillin 6) Otrivine nasal drops (not under 2 years old) 7) 4 hourly neuro obs 8) Emergency CT scan of Brain and Orbits if impairment on eye examination 9) Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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ACUTE ANGLE CLOSURE GLAUCOMA
Symptoms:
Pain, blurred vision, coloured haloes around lights, frontal headache, nausea and vomiting
Signs:
Hazy cornea, red conjunctiva, mid-dilated pupil that doesn’t respond to light
Patient usually elderly and long-sighted
Measure intraocular pressure if possible (Ophth nurses on Ward 4A) – pressure will be greater than 35mmHg.
Management:
1) Admit Ward 4A 2) Actetazolamide 500mg IV stat then 250mg PO (or IV) qds 3) Latanoprost eyedrops od, Timoptol 0.25% eyedrops bd, Iopidine 1% eyedrop tds, Pilocarpine 2% qds - all to affected eye 4) If still pain/vomiting 2 hours after above treatment give Mannitol 10% 500ml IV infusion over 60 minutes unless contraindicated 5) Nurse supine 6) Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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CORNEAL ULCER
Corneal infection with overlying ulcer / defect in the corneal epithelium
Causes:
1. Bacterial 2. Viral (Herpes simplex) 3. Others (rare) - Fungal, Acanthamoeba
Risk factors:
• Contact lens use • Blepharitis (sticky eyelashes, red eyelids) • Severe dry eye, especially elderly • Previous Herpes simplex virus of eye or skin
Symptoms
• Red eye • Watery eye • Pain – strong foreign body sensation or more severe constant pain • Photophobia - pain in bright light • Reduced vision
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Signs:
• Use Proxymetacaine local anaesthetic drops to reduce pain and allow examination / swabs • Grey / white opacity in cornea - typically fairly central rather than at very edge of cornea • Fluoroscein drops - ulcer stains green in blue light • Red eye maximal around corneal edge • Hypopyon (white ‘fluid level’ visible against inferior iris) • Dendritic ulcer (branching linear pattern) indicates Herpes simplex
Management:
• If Herpes simplex dendritic ulcer - Ganciclovir ointment 5 times daily , review Ophthalmology within 72h
• All other corneal ulcers - treat as bacterial keratitis:
1. Conjunctival swab for C&S 2. Corneal swab from ulcer for C&S 3. If contact lens and / or contact lens case available - send for C&S 4. Admit to Ward 4A, side room 5. Ofloxacin drops hourly day and night 6. Cyclopentolate 1% drops three times a day 7. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.
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SUDDEN VISUAL LOSS
Central retinal artery occlusion (CRAO)
Causes of CRAO:
1) Thromboembolic (common) 2) Giant Cell Arteritis (rare)
Symptoms:
Sudden profound loss of vision in one eye
May have had amaurosis fugax in preceding days/weeks
May have history of cardiovascular risk factors.
Painless, white eye
Signs:
Visual acuity: usually only counting fingers or worse.
Relative afferent pupillary defect present
Pale retina (subtle) with cherry red spot at fovea may be visible on fundoscopy
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Management:
Must exclude Giant cell arteritis if >50years old-
- History of GCA symptoms/ polymyalgia (jaw claudication, etc) - Raised inflammatory markers PV/ESR, CRP - Can have raised acute phase proteins, alk phos, Platelets, gamma GT - Can have a normocytic anaemia
1) Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose 2) If no suspicion of GCA arrange for follow up with Ophthalmology that day or, if out of hours, the following day 3) If GCA is clinically suspected: -Admit to Physicians -1g IV Methyl Prednisolone as soon as possible -Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Central retinal vein occlusion (CRVO)
Symptoms:
Sudden loss of vision in one eye (can be mild - severe)
May have history of cardiovascular risk factors
Painless, white eye
Signs:
May have relative afferent pupillary defect
Retinal flame shaped haemorrhages may be visible on fundoscopy
Management:
1) Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose, TFTs
2) Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.
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Anterior ischaemic optic neuropathy (AION)
Symptoms:
Sudden loss of vision or visual field in one eye
Visual field defect
May have had amaurosis fugax in preceding days/weeks
Check for symptoms of GCA (jaw claudication, etc)
White eye
Signs:
May have altitudinal visual field defect (loss of either top half or bottom half of visual field)
Will have afferent pupillary defect
Swollen pale disc + disc haemorrhages on fundoscopy
Management:
Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose
Must exclude Giant cell arteries if >50years old
- If history of GCA symptoms/ polymyalgia - Raised inflammatory markers PV/ESR CRP - Can have raised acute phase proteins alk phos, Platelets, gamma GT - Can have a normocytic anaemia
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If GCA is clinically suspected:
1) Admit to Physicians 2) 1g IV Methyl Prednisolone as soon as possible 3) Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Amaurosis fugax
Symptoms:
Sudden transient unilateral loss of vision – usually lasts secs-mins
May have a history of cardiovascular disease or known risk factors
Painless, white eye
Signs:
Normal vision and visual field
No afferent pupillary defect
Management:
Follow up to date TIA protocol found at:
http://tam.nhsh.scot/treatments-and-medicines/therapeutic- guidelines/stroke/referral-of-tias-or-new-minor-strokes-to- neurovascular-clinic-raigmore/
Refer to Neurovascular Clinic by email
NB GCA can occasionally present as amaurosis fugax – check for consistent history
Must exclude Giant cell arteries if >50years old
- If history of GCA symptoms/ polymyalgia
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- Raised inflammatory markers PV/ESR CRP - also can have raised acute phase proteins alk phos, Platlets, gamma GT - can have a normocytic anaemia
If GCA is clinically suspected
1) Admit to Physicians
2) 1g IV Methyl Prednisolone as soon as possible
3) Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Macular haemorrhage
Symptoms:
Sudden unilateral central loss of vision (but with preserved peripheral visual field)
Painless, white eye
May have recent preceding history of distortion of central vision
May have a history of macular degeneration
Signs:
Reduced visual acuity
No afferent pupillary defect
Haemorrhage seen at macula (central retina) on fundoscopy
Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Vitreous haemorrhage
Symptoms:
Progressive loss of vision or shadow in one eye
Floaters may be present
Painless, white eye
Often have a history of diabetic retinopathy or previous retinal vein occlusion
Signs:
Reduced vision (variable degree)
No afferent pupillary defect
No red reflex on ophthalmoscopy
No view of retina on ophthalmoscopy
Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Retinal detachment
Symptoms:
Progressive loss of vision or shadow in one eye
Flashing lights and floaters.
Painless, white eye
May have a history short sightedness, or blunt trauma
May have a family history of retinal detachment
Signs:
Vision may be reduced (variable)
Visual field defect may be present
Afferent pupillary defect may be present
May see detached retina on ophthalmoscopy
Management:
Position on back
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Optic neuritis
Symptoms:
Gradual reduced vision in one eye
Pain behind eye on eye movement
May have history of MS or other neurological symptoms
Signs:
Reduced visual acuity in affected eye (variable)
Desensitivity to colour red on comparison with fellow eye
Relative afferent pupillary defect
Optic nerve may be swollen or normal on ophthalmoscopy
Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Functional visual loss
Diagnosis of exclusion
Common in children
Suspect when poor vision is reported but visual behaviour doesn’t support this
Ensure there is no relative afferent pupillary defect
Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day
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Migraine
Symptoms:
Transient visual disturbance then returns to normal
Unilateral or bilateral
Typically lasts 15-20 minutes
May describe strobing, zig-zags or kaleidoscope effects
May be followed by headache
May have previous migraine history
Signs:
Normal examination once settled
Management:
Reassurance
No follow up normally required
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RED EYE
Foreign body: corneal/conjunctival/subtarsal
Symptoms: Pain, foreign body sensation, decreased vision, watering
Signs: Foreign body visible on cornea or conjunctiva, linear corneal abrasions with fluorescein (subtarsal foreign body)
Management: Topical anaesthetic: Proxymethacaine drops Evert lid if subtarsal Remove foreign body if possible
If foreign body removed: Chloramphenicol ointment qds for 5 days Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home Oral analgesia as required Discharge
If can’t remove foreign body: Chloramphenicol ointment qds for 5 days Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home Oral analgesia as required Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.
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Corneal abrasion
Symptoms: Pain and photophobia, watering, decreased vision
Signs: Corneal epithelial disturbance (but no corneal opacity) which stains well with fluorescein, red conjunctiva
Management: Chloramphenicol ointment qds for 5 days Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home Oral analgesia as required Discharge
Arc eye
Symptoms: Few hours after welding (or sunbed use) Pain and photophobia, watering, decreased vision
Signs: Red conjunctiva, mild corneal haze, diffuse punctuate corneal staining with fluorescein
Management: Chloramphenicol ointment qds for 5 days Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home Oral analgesia as required Discharge
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Conjunctivitis
Symptoms: Itching, burning, gritty, watery or discharging eyes
Signs: Red and oedematous lids and conjunctiva, discharge on lashes
Management: Conjunctival swab if possible Chloramphenicol ointment qds for 5 days Liquifilm tears qds for lubrication if required Oral analgesia as required Discharge
Iritis
Symptoms: Increasing pain and especially photophobia, decreasing vision
Signs: Red conjunctiva - especially adjacent to corneal limbus Check cornea is normal (including with fluorescein) to exclude a corneal ulcer
Management: Predforte or Maxidex hourly during day Cyclopentolate 1% tds Oral analgesia as required Ophthalmology review in clinic within 3 days – refer by email
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Sub-conjunctival haemorrhage
Symptoms: If no trauma involved usually asymptomatic, sometimes foreign body sensation
Signs: Blood under conjunctiva obscuring underlying sclera
Management: Liquifilm tears qds for lubrication if required Discharge
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