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Ophthalmology Emergency Protocols

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OPHTHALMOLOGY EMERGENCY PROTOCOLS (click headings to jump to text) 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 1 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. 2 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 3 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 4 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 5 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 6 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 7 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 8 • 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 9 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
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