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Home , Enophthalmos, Hypopyon, Optic neuropathy

Common eye emergencies The acute , sudden visual loss or trauma are the most common eye emergencies.

KAVITHA NAIDU, MB ChB, FCOpth Consultant, Department of , Nelson Mandela School of Medicine, KwaZulu-Natal, Durban Kavitha Naidu qualified in 2003 as an ophthalmologist at the Nelson Mandela School of Medicine. She is currently a consultant in the Department of Ophthalmology and is based at St Aidans Hospital. Her fields of interest include ocular trauma and retinal disease and surgery, especially diabetes and .

Common eye emergencies may present as an acute red eye, sudden a painful red eye, swelling or chemosis of the , a profuse, visual loss or acute ocular trauma. Most eye emergencies will require thick yellow-green purulent discharge and tender pre-auricular referral to an ophthalmologist after initial basic examination and lymph nodes. Untreated, the infection may spread to the primary management. A relevant history of onset and symptoms of and cause peripheral corneal ulceration with eventual perforation the current problem must be obtained and, in the case of trauma, and possible infection of the whole eye (panophthalmitis). the exact mode and time of . Any relevant medical, family or Suspicion of this condition therefore should lead to referral to an previous ocular history must also be elicited. ophthalmologist. Treatment of gonococcal is with a stat dose of intramuscular ceftriaxone, followed by frequent instillation of topical ciprofloxacin or chloramphenicol eyedrops Acute red e ye or penicillin, bacitracin or erythromycin ointment. This is Causes of an acute red eye include conjunctivitis, , accompanied by ocular irrigation prior to medication to remove , , uveitis and acute-angle closure . the copious discharge. The patient and sexual contacts must also be treated with a course of oral tetracycline or erythromycin. Acute conjunctivitis Viral conjunctivitis Acute conjunctivitis may be bacterial, viral or allergy related. This is an extremely common condition. It starts unilaterally and affects the second eye within 1 week, presenting with Bacterial conjunctivitis conjunctival hyperaemia, a watery discharge and pre-auricular Acute bacterial conjunctivitis begins unilaterally with hyperaemia, lymphadenopathy. Most cases resolve spontaneously without irritation, tearing, and a mucopurulent discharge. Common sequelae within a few days to 3 weeks. Specific viruses can cause pathogens include Staphylococcus aureus, Streptococcus associated clinical ocular and systemic signs. pneumoniae and Haemophilus influenzae. The latter two occur Adenovirus causes pharyngoconjunctival fever and epidemic commonly in children and may occur in institutional epidemics. . The former is characterised by a Treatment consists of topical broad-spectrum antibiotic drops combination of pharyngitis, fever and conjunctivitis. Epidemic or ointments with good Gram-positive cover such as a third- or keratoconjunctivitis produces a more severe, extremely contagious fourth-generation fluoroquinolone, or trimethoprim-polymixin. conjunctivitis, with subconjunctival haemorrhages and ipsilateral Conjunctivitis generally lasts 7 - 10 days. pre-auricular lymphadenopathy and often leads to corneal Gonococcal conjunctivitis (Fig. 1) occurs primarily in neonates involvement. Treatment is symptomatic and involves minimisation and sexually active young adults. Affected individuals present with of transmission. Acute haemorrhagic conjunctivitis presents as a painful conjunctivitis with subconjunctival haemorrhages. It tends to occur in epidemics and the conjunctivitis lasts 4 - 6 days with the haemorrhages resolving more slowly.

Fig. 2. Herpes simplex blepharoconjunctivitis. Fig. 1. Gonococcal conjunctivitis.

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Herpes simplex conjunctivitis type 1 (Fig. inflammatory nodules consisting of whereas fungal ulcers have poorly defined 2) occurs in children under 5 years and may hypertrophic lymphoid tissue can be seen. borders and satellite lesions. Patients require be associated with vesicular eruptions Due to the chronicity and sight-threatening specialist assessment with a slit lamp to detect and corneal involvement. Type 2 herpetic consequences of the corneal aspect of this specific clinical features and for corneal conjunctivitis is seen in newborns or adults disease, patients must be assessed by a scraping for microscopy and culture, so that with previous orogenital contact. Treatment specialist. antimicrobial treatment may be commenced is with topical antivirals. Corticosteroids appropriately. Under no circumstances must should be avoided as they enhance the Keratitis steroid eye drops or ointment be offered severity of coexistent keratitis. Infectious keratitis or corneal ulceration to the patient prior to referral as this will worsen the clinical outcome. Other causes of self-limiting viral may be bacterial, viral, fungal or protozoal. conjunctivitis include rubella, rubeola, Predisposing factors include contact varicella zoster, Epstein-Barr and Newcastle wear, corneal injury and ocular surface disease viruses. disease, including any condition disrupting ocular surface defence mechanisms such as dry eye, post-herpetic corneal disease, and corneal exposure. Patients who are Acute atopic conjunctivitis is an IgE- immunocompromised are at risk of more mediated allergic response precipitated aggressive forms of keratitis. by airborne allergens such as dust, pollen, spores and animal dander. Patients Corneal ulceration caused by the fresh and complain of itching, burning, and may have salt water Acanthamoeba species is typically a watery or mucoid discharge, as well as seen in young patients who wear contact nasal and respiratory symptoms. There is lenses and who wash their lenses or lens cases Fig. 5. Corneal ulcers. usually a family history of atopy. Treatment in tap water. It presents as an unbearably involves the use of topical antihistamines, painful, injected eye with and mast cell stabilisers, vasoconstrictors, non- decreased visual acuity. steroidal anti-inflammatories and steroids is particularly severe in where necessary. A perennial form of acute HIV-positive patients and diabetics. It is atopic disease may occur in conjunction sometimes associated with a preceding with seasonal changes and is treated on a corneal injury involving vegetable matter symptomatic basis. contact with the eye and is seen in farm Giant papillary conjunctivitis occurs labourers. in contact lens wearers and may present Viral keratitis is most commonly caused acutely, in spite of a long history of lens by HSV-1 in children with associated wear. Symptoms consist of ocular irritation, blepharoconjunctivitis. Herpes zoster mucoid discharge and foreign body Fig. 6. Viral dendritic . ophthalmicus (Fig. 4) is seen increasingly sensation. in HIV-positive patients, and keratitis is Vernal keratoconjunctivitis (Fig. 3) particularly common if the characteristic Episcleritis and scleritis presents similarly to perennial allergic dermatomal vesicular rash involves the Episcleritis typically affects young adults. disease, but is seen in children up to 13 tip of the nose. Patients may also have It is self limiting, often not requiring any years and is increasing in incidence in HIV- conjunctivitis, anterior uveitis, glaucoma, medication, but is frequently recurrent. It positive adults. Symptoms are photophobia, scleritis, and second to eighth presents with unilateral mild discomfort, tearing, decreased vision, burning sensation cranial nerve palsies. tenderness to the touch and a watery eye with of the eyes and a thick ropy discharge, which redness over a localised or diffuse area of the is worse in the mornings. Patients often . Slit lamp examination is required to have associated respiratory allergic disease differentiate episcleritis from scleritis, which such as rhinitis, asthma and/or eczema. On is much less common but may have sight- examination the are swollen with threatening consequences. an injected cobblestone appearance on lid Scleritis is inflammation of the sclera which eversion. These are giant papillae, which may be insignificant and self-limiting, or can cause irritation and mechanical damage associated with necrosis (Fig. 7) and lead to the cornea, resulting in ulceration and to keratitis, uveitis, glaucoma, , scarring. On the corneal limbus, whitish retinal oedema and . Fig. 4. Herpes zoster ophthalmicus. About 45% of patients with scleritis have systemic conditions such as rheumatoid arthritis, connective tissue diseases such General symptoms of all forms of keratitis as Wegener’s disease, systemic lupus (Fig. 5) are blurring of vision, , especially erythematosus and polyarteritis nodosa, on blinking, tearing and a discharging eye. and other miscellaneous conditions such Clinical features include eyelid oedema as herpes zoster. Presentation of scleritis and discharge, conjunctival hyperaemia, is similar to episcleritis, but patients may greyish-white area of defect or ulceration have more severe pain and associated visual on the cornea, and a hypopyon (pus in the impairment. anterior chamber). The specific features of the corneal ulcer give clues to the aetiology, Fig. 3. Vernal keratoconjunctivitis. e.g. viral ulcers appear dendritiform (Fig. 6)

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Fig. 7. Necrotising scleritis. Uveitis Fig. 8. . Fig. 10. Retinal vein occlusion. Acute uveitis presents with injection surrounding the cornea and the patient Central retinal artery occlusion Anterior ischaemic optic complains of photophobia, pain, tearing and A patient with a central retinal artery neuropathy blurring of vision. Slit lamp examination occlusion will complain of sudden total This condition occurs as a result of infarction shows the presence of active inflammation visual loss. On history, certain systemic within the . It may be associated in the anterior chamber. Inflammatory risk factors such as carotid artery disease, with and systemic vascular nodules may also be seen on the . Uveitis hypercholesterolaemia and giant cell diseases, in which case it occurs typically in may be associated with infections, systemic arteritis may be present. On examination, the elderly. In patients between 45 and 65 diseases or it may be idiopathic. the will be non-reactive to light and the years old who are hypertensive or healthy, fundus appears pale with a central ‘cherry- anterior ischaemic optic neuropathy can Acute-angle closure glaucoma red spot’ at the fovea (Fig. 9). Preliminary occur as an isolated event. Presenting features This condition occurs due to a sudden rise emergency treatment involves applying firm are uniocular, sudden and sometimes in intraocular pressure, when the drainage ocular massage intermittently for at least 15 profound visual loss, with periocular pain, angle of the eye becomes totally occluded minutes, in the hope that intraocular pressure visual obscurations and flashing lights. The by the peripheral iris. It usually occurs in will decrease and blood flow will increase, involved pupil may be non-reactive to light. patients who demonstrate an anatomical dislodging the emboli causing the occlusion. There may be a defect of half of the visual predisposition to angle closure, and is The patient must then be promptly referred field, and colour vision is diminished. The frequently bilateral. Patients complain of for further management. optic nerve appears pale and swollen and periocular pain and progressively decreasing may be surrounded by splinter-shaped vision, with associated nausea and vomiting haemorrhages (Fig. 11). in severe cases. There may be a history of a previous similar attack which resolved. The eye is congested and inflamed, the cornea is hazy and the anterior chamber may appear shallow with a mid-dilated pupil. The eye will feel digitally firm and will be tender. Patients require immediate intraocular pressure lowering agents and further specialist management.

Fig. 9. Central retinal artery occlusion. Sudden visual loss Retinal vein occlusion Causes of sudden loss of vision are retinal detachment, central retinal artery occlusion, Patients with a suspected retinal vein occlusion retinal vein occlusion, anterior ischaemic will complain of decreased vision in part of or the Fig. 11. Anterior ischaemic optic neuropathy. optic neuropathy, optic neuritis, vitreous whole visual field, which may be accompanied haemorrhage and posterior uveitis. by distortion in vision. Systemic predisposing Optic neuritis factors are increasing age (6th to 7th decades), Optic neuritis is a condition where there Retinal detachment systemic hypertension and blood dyscrasias is inflammation in the optic nerve, and such as chronic leukaemia, polycythaemia, Clues as to the presence of a retinal therefore decreased vision. It may be Waldenstrom’s macroglobulinaemia and sickle detachment are a history of seeing flashing associated with or may cell disease. Ocular risk factors are raised lights, floating opacities in the eye and the be related to systemic infection, especially intraocular pressure, hypermetropia, congenital presence of a curtain or shadow of darkness in children, where it follows viral infections central retinal vein anomaly and periphlebitis with loss of vision in the eye. Patients may such as measles, mumps, , as seen in and Bechet’s disease. The have risk factors such as being myopic, whooping cough, glandular fever and pupil of the affected eye may be sluggish or non- having a family history of retinal detachment immunisation. Patients have monocular reactive. On fundal examination, the veins look or having had a recent contusive injury to visual loss, which frequently is accompanied dilated and tortuous and there are flame-shaped the head or eye. Fundal examination reveals by periocular discomfort, which is worse on and dot and blot haemorrhages with retinal a poor red reflex and the appearance of lifted eye movement. Associated tenderness oedema and cottonwool spots in the area of the (Fig. 8). and frontal headache can occur. In children retina drained by the obstructed vein (Fig. 10). both eyes may become involved and other

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neurological features such as seizures or ointment such as chloramphenicol and ataxia may occur. On ocular examination the padding the eye for 24 hours to encourage pupil is sluggish or non-reactive, and there is epithelial healing. diminished colour vision and sensitivity to If there is a suspicion that a foreign body may light in the affected eye. have penetrated the eye, the patient should reveals a swollen optic nerve head or be promptly referred to an ophthalmologist papillitis (Fig. 12). who will do a dilated fundoscopy, X-ray and CT scan to confirm the presence and exact location of the foreign body and plan surgical removal of it.

Welding may result in a condition called Fig. 15. Subconjunctival haemorrhage with ‘arc eye’, which occurs when a patient is not corneal abrasion staining with fluorescein dye. wearing protective eyewear, causing painful, injected eyes. Treatment is with topical anaesthetic eye drops, double eye padding, oral analgesia and a non-steroidal or weak steroid eye drop depending on the degree of inflammation. Contusive eye caused by a blow to the eye can result in a wide range of intraocular Fig. 12. Optic neuritis. damage which can only be detected with a slit lamp or with dilated fundus examination. A vitreous haemorrhage, especially in Orbital blowout fractures (Fig. 13) result from diabetics, and posterior uveitis, can also a blow to the eye which produces a sudden Fig. 16. Hyphaema. cause sudden visual loss and clinically have rise in the intraorbital pressure. This causes a poor red reflex on examination. the walls of the to fracture, sometimes entrapping in the process. Patients have periocular ecchymosis Acute ocular trauma and oedema, subcutaneous emphysema, Acute ocular trauma consists of mechanical, a restrictive , decreased ocular chemical, thermal and combination eye motility, , anaesthesia of the injuries. cheek and complain of double vision. An X- ray examination may show orbital fractures Mechanical eye injuries but a CT scan and specialist assessment are These present as non-penetrating or required for possible surgical orbital repair. penetrating/perforating eye injuries. Fig. 17. Contusive with mid- dilated pupil with blood in the vitreous and lens Non-penetrating eye injuries dislocation. The commonest non-penetrating injuries seen are a foreign body on the eye and Globe injuries will all require specialist a corneal abrasion. Patients may have intervention except subconjunctival felt something enter their eye, may have haemorrhages (Fig. 15), which are self- been grinding, hammering or chiselling, limiting and require only reassurance to mowing the lawn or may present with an the patient. A hyphaema (Fig. 16), which uncomfortable feeling on closing the eye, is blood in the anterior chamber of the eye, tearing and redness of the eye. can be recognised as a level of blood or a blood clot obscuring the iris and sometimes On examination there may be a visible Fig. 13. . the pupil. Any irregularities in the iris, lens break in the epithelial surface which can be (Fig. 17) or on fundus examination or any confirmed by seeing yellow-green staining Any proptosis (Fig. 14) must be referred for non-penetrating injury where there is visual on installation of flourescein eye drops. A an orbital CT scan to exclude the presence affectation must be seen by a specialist. foreign body may be seen on the corneal of a retrobulbar haematoma after careful surface, in the fornices or on eversion of the documentation of the pupillary response, Penetrating and perforating eye upper lid. which indicates the presence of pressure on injuries Most superficial foreign bodies can be the optic nerve. Minor lid lacerations may be sutured, but removed; however, some may be deeply those involving the lid margin, tarsal plate or embedded in the cornea and these patients lacrimal drainage system must be referred. will require referral for removal under slit Ocular lacerations are recognised as a break lamp magnification. Topical anaesthetic in the cornea (Fig. 18) or scleral continuity drops should be instilled and a cotton-tipped (Fig. 19) and may have protruding iris, applicator is used to manipulate the foreign vitreous or brown uveal tissue visible. There body off the eye. Further management after Fig. 14. Traumatic proptosis with retrobulbar may also be a hyphaema present, shallow removal of corneal foreign bodies and of haematoma. anterior chamber of the eye, distortion of corneal abrasions entails using an antibiotic the pupil, iris and lens damage.

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Gunshot wounds to the orbit cause Thermal injuries perforating or through-and-through globe Injuries caused by sparks from a fire, injuries, sometimes damaging the eye to match or boiling water vary, depending the extent that it becomes disorganised. on the degree of contact with the eye. Surrounding orbital tissue and bones are Corneal abrasions commonly result and also severely damaged in the process. surrounding skin and scalp may also need Patients’ general condition must be attention. primarily attended to, due to the high risk of concurrent intracranial injury. Combination injuries Being a surgical emergency, penetrating These comprise eye trauma related to or perforating injuries require prompt fireworks, blasts and motor vehicle Fig. 18. Corneal laceration. referral after the patient has received accidents, all of which require referral after topical antibiotics, systemic analgesia, initial assessment to exclude other injuries tetanus prophylaxis, and eye padding. to the body and pain control.

Chemical injuries Further reading Kanski JJ. Clinical Ophthalmology – A Systematic Chemicals commonly responsible for Approach. Oxford: Butterworth-Heinemann, eye injuries are household detergents, 2003. bleaches and disinfectants. Fertilisers, Kuhn F, Pieramici DJ. Ocular Trauma– Principles pesticides and industrial chemicals in the and Practice. New York: Thieme Medical occupational sector are potent and can Publishers, 2002. cause severe ocular damage, especially Kirk RW, Andrew JW, et al. External Disease and alkaline solutions which tend to penetrate Cornea. Basic and Clinical Science Course. San Fig. 19. Scleral laceration with visible uveal the eye long after contact. It is crucial to Francisco: American Academy of Ophthalmology, tissue. establish the chemical responsible and to 1998. irrigate the eye with normal saline or sterile Visser L. Common Eye Emergencies and Stab injuries to the orbit are particularly Procedures – Lecture Notes for General prone to severe infection of the globe water immediately. Topical anaesthetics Practitioners 2005 (unpublished). should be used for eye pain, the eye must (panophthalmitis) and orbital sepsis which Yanoff M, Duker J. Ophthalmology. 2nd ed. St may spread to the brain. Patients should be padded and the patient referred. Louis: Mosby, 2003. therefore be commenced on systemic antibiotics as prophylaxis. In a nutshell • Common eye emergencies comprise the acute red eye, sudden visual loss and acute ocular trauma. • The acute red eye can present as conjunctivitis, keratitis, episcleritis, scleritis, uveitis and acute-angle closure glaucoma. • Sudden visual loss can be due to retinal detachment, central retinal artery occlusion, retinal vein occlusion, anterior ischaemic optic neuropathy, optic neuritis, vitreous haemorrhgae and posterior uveitis. • Acute ocular trauma can be due to mechanical, chemical, thermal or combination injuries. • Most emergencies will require a general and ocular assessment before referral to a specialist.

Single suture Coffee may delay dementia Evidence from a sample of adults in the community aged at least 65 shows that caffeine intake seems to reduce cognitive decline in women who do not have dementia, especially in older women, according to Karen Ritchie and colleagues writing in Neurology. They studied 4 197 women and 2 820 men from three French cities. No effect on the incidence of dementia was seen, but drinking more than 3 cups of coffee a day may be able to prolong the period of mild cognitive impairment in women before a formal diagnosis of dementia is made. Ritchie K et al. Neurology 2007; 69: 536-545.

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