Ocular Emergencies: Quick Reference

Sight is precious, considered by many to be the most essential of the five senses. In children, eyesight is even more important because good vision is often related to learning. Regular eye examinations are important to maintain proper eye health, since some serious eye disorders produce no early warning symptoms. Although prevention is the best defense, eye problems or injuries still can occur suddenly and unexpectedly. And when they do, recognizing their signs and symptoms and knowing what to do is vital to preserving sight.

This guide is a quick reference for identifying common traumatic and non-traumatic ocular emergencies. Its simple format and language are directed at school nurse eye care providers with specific emphasis in aiding physicians and staff in the diagnosis of vision-threatening eye emergencies at times requiring ophthalmic consultation. It will prepare the emergency eye care provider with the information and tools necessary to effectively triage and manage common eye emergencies.

When a student comes in with a red eye it is of the utmost importance that a very thorough and complete history be taken. The history should contain when the condition started or when it happened. What were the circumstances/conditions surrounding the incident.

a) Was the patient hit in the eye with something and if so with what? Wood, metal, glass, pizza, etc.; or were they hammering on something if so, on what, with what?

b) When did the condition start? Was it a week ago, this morning, two days ago, just when did the student first notice the condition.

c) Has the student taken any thing for pain, if so what and has it helped? Has he/she put anything in his/her eye, if so what? In other words, has there been an attempt to treat the condition? If there has been a treatment, what was its nature? With what? Was a vasoconstrictor involved, which now makes the eye less red?

d) You need to know as much about the cause as you can elicit from the student. This should start you thinking about what you are looking for, how severe the condition may be, and what kind of treatment you may have to initiate. If the injury has resulted because the student was hammering metal on metal, for example, you have to think about the possibility of a penetrating foreign body due to the higher speed of the projectile as opposed to something "falling" in the eye.

e) If you determine the student does have a penetrating injury only use a shield or the lower part of a paper cup, with no wax coating, and apply just enough tape to hold it in place. DO NOT PRESSURE PATCH! Students then must be referred to an eyecare provider.

There are certain conditions that you do not want to patch.

First, students with a corneal ulcer. Even though you may be using a wide spectrum antibiotic under the patch the cornea has an open infection. There are certain microorganisms that antibiotics might not be able to combat. The patch makes for a nice warm moist dark environment for them in which to grow.

Second, students who have developed abrasions secondary to contact lens over wear. Since, it was the contact lens covering the cornea that caused the problem in the first place it is not prudent to keep the cornea covered again using a patch. Studies have shown that in these cases the corneas healed much faster when not patched. This means the student should be dilated and medicated, sometimes around the clock depending on the severity of the contact lens induced keratitis. Pressure patching prevents fully medicating the student and hence is strongly contraindicated. Additionally, the patch will further deprive the cornea from oxygen.

Third, chemical burns are also contraindications for patching. The chemical agent may not have been thoroughly lavaged from the eye. Patching will allow extended exposure to the agent under closed lids and is strongly contraindicated.

Ocular trauma in a school setting is unexpected and can result in dramatic vision loss. Some of the most insidious yet serious ocular injuries result from inadvertent ocular accidents, and therefore emergency care providers should have a high degree of suspicion when evaluating eye injuries. This quick guide presents a series of ocular incidences and the methods to uncover the proper referral or management in order to advert ocular injury.

A student who complains of irritation when blinking might have a foreign body under the upper lid, which might produce a corneal abrasion. In cases of blunt perforating injury to the eye or penetration by large objects, the diagnosis is obvious. The student might complain of dramatically decreased vision and usually will be in significant pain. The lids are often too swollen to open, and referral to a specialist is not in doubt. This presentation, however, is in stark contrast to the presentation of an intraocular foreign body, which is usually quite small and does not result in major lid edema.

If penetration has occurred, the student will usually complain of moderate ocular pain, redness, and watering. Impaired vision is not a reliable indicator of an intraocular foreign body, since visual acuity might remain excellent as long as the visual axis is not involved. If, however, the injury results in corneal distortion, a cataract, vitreous hemorrhage, or macular damage, the vision can be dramatically reduced.

Physical examination is critical in making the diagnosis and determining which injuries might be vision-threatening. At track meets, a cinder might be found on the cornea or under the upper lid. Do not rub the eye. Lift the upper lid over the lower lid allowing the lower lashes to brush the speck off the inside of the upper lid. Blink a few times and let the eye move the particle out. If the speck is under the eyelid a flashlight may be used to detect a corneal foreign body; and careful eversion of the eyelid with a cotton swab will often demonstrate conjunctival foreign bodies. (figure "Foreign Body In Eye"). A procedure for everting an upper lid is shown in figure

1. Patients who have corneal foreign bodies rarely develop infection if the objects are removed immediately.

A direct blow to the eye and surrounding tissues causes a "blunt injury." This may result in a spectrum of injuries ranging from a simple ‘black eye’ to severe intra-ocular disruption, including rupture of the globe. Immediately apply an ice compress to the eye to reduce pain and swelling. A black eye or blurred vision can be a sign of damage inside the eye.

When the eye is struck, it is compressed stretching in the equatorial plane, which causes a combination of contusional and tearing damage. The increase in intra-orbital pressure may result in a blow out fracture as the floor of the orbit decompresses into the maxillary sinus. This is a rare but important type of facial fracture that may result in damage to the inferior rectus muscle and orbital septae causing restriction in eye movements and diplopia, both of which are difficult to treat effectively.

When the eye is struck, the cornea is flattened and the intra-ocular pressure rises rapidly. The anterior chamber is compressed and the pupil is forced to dilate rapidly which may tear areas of the sphincter muscle of the iris, causing traumatic dilation. The aqueous humour is forced peripherally, leading to damage to the drainage angle which, if extensive enough predisposes to glaucoma at a later date. Bleeding from any of these areas of the highly vascular iris causes a hyphaema (blood in the anterior chamber), and the hyphaema is the hallmark of severe intra-ocular blunt trauma. Most hyphaemas absorb spontaneously within 2-6 days of the injury and the prognosis of an uncomplicated hyphaema is excellent. The importance of a hyphaema is that its presence indicates that the eye has suffered a significant injury, and structures within the anterior and posterior segments are likely to be damaged, which may require emergency treatment. A full ocular assessment is, therefore, mandatory, paying particular attention to the intra-ocular pressure, structures within the drainage angle, clarity and stability of the lens, the posterior pole and the peripheral retina.

Red eyes is a common term for a condition called conjunctivitis, which itself simply means inflammation of the white of the eye. Red eyes can be caused by many things such as bacteria, viruses, allergies, dryness, improper contact lens wear and blood vessels that have burst. Symptoms depend upon the underlying cause of the red eyes. Below are the typical symptoms that are usually associated with each type of red eye problem:

Bacterial: bright red eye, discharge (pus), burning sensation

Viral (Pink Eye): pinkish eye colour, watering, tiny dot hemorrhages on the white of the eye, burning sensation

Allergic: pale red eye, itching, thick & stringy discharge (pus), watering

Dryness: mild redness, dry & scratchy sensation (people often describe it as though there is sand in the eyes), sometimes watering

Improper contact lens wear: discomfort & redness that is worse when wearing contact lenses

Burst blood vessel: bright & solid red eye, no other associated symptoms

Treatment for red eyes depends upon the underlying cause of the condition. Listed below are the usual treatment options for each type of problem:

Bacterial: treatment of a bacterial infection varies greatly depending upon the type of bacteria. For mild infections that are not sight threatening, a broad-spectrum antibiotic eye drop such as Polycidin or Polysporin will do the job. For more serious infections, stronger prescriptions such as Tobramycin or Ciprofloxacin antibiotics are necessary.

Viral (Pink Eye): the common adenoviral agents causing red eyes such as pink eye need no treatment at all. Antibiotics target bacteria, not viruses, and are therefore unnecessary. Usually recommend are the use of artificial tears and cold compresses simply to provide symptomatic comfort. More serious viral infections such as Herpes Simplex are treated aggressively with anti-viral prescription eye drops.

Allergic: for acute cases of red eyes due to allergies, treatment includes ocular decongestant eye drops that contain anti-histamine with cold compresses. For more chronic cases, stronger eye drops such as prescription Patanol and Zaditar will provide fast and prolong relief. These drops don't just counteract histamine that is naturally released by the body (like anti-histamines), they block the release of histamine.

Dryness: for most people, dry eyes are easily treated with moisturizing artificial tear eye drops. For more difficult cases ointments at bedtime will provide prolong relief.

Improper contact lens wear: treatment depends upon the cause of the problem. If the red eyes are due to dirty contact lenses, then acquiring new lenses is recommended. If redness is caused by tight fitting contact lenses, then a refit is necessary. If the contact lens is damaged then the lens needs to be replaced.

Burst blood vessel: this is a harmless condition that looks like a serious eye condition. A tiny blood vessel in the white of the eye has blood trapped between the tissue layers of the eye and it easily spreads over the eye due to gravity. It generally clears up in about 2 weeks with no treatment necessary. If this occurs on a regular basis, then it may indicate an underlying condition such as high blood pressure or hemophilia. To increase the absorption of the blood into the bodies tissue the use of warm compresses will aid the process.

The diagnosis of chemical trauma to the eye is typically based upon the history, rather than the signs and symptoms. Students generally report varying degrees of pain, photophobia, reduced vision, and colored haloes around lights. Flood the eye with water immediately, using your fingers to keep the eye open as wide as possible. Hold the student's head under a faucet or shower, or pour water gently into the eye from a container for at least twenty to thirty minutes. Roll the eyeball as much as possible to wash out the eye. Do not use an eyecup, or bandage the eye.

In mild to moderate burns, the eye is hyperemic and may display conjunctival chemosis, eyelid edema, first degree burns to the skin, and cells and flare in the anterior chamber. Corneal findings may range from diffuse superficial punctate keratopathy to focal epithelial erosion with mild stromal haze.

When the chemical injury is severe, the eye is not red but appears white due to ischemia of the conjunctival vessels. Chemosis of the lids and conjunctiva is evident, and surrounding facial areas may demonstrate second or third degree burns. Corneal findings include total epithelial erosion with edema and dense stromal hazing, and sometimes complete opacification

Both acidic (pH<4) and alkaline (pH>10) solutions are capable of inducing a chemical burn. Acids tend to bind with tissue proteins and coagulate the surface epithelium. This bars further penetration so acid burns are typically confined to superficial tissues. Most commonly, acid burns to the eye result from exploded car batteries, which contain sulfuric acid.

Alkaline burns occur more frequently and are generally more severe than acid burns. These solutions destroy the cell structure not only of the epithelium but also of the stroma and endothelium. While acids create an initial burn and then cease, alkalis may continue to penetrate the cornea long after the initial trauma. Common sources of alkalis include ammonia, lye and lime.

Burns to the eye caused by strong acids or alkalis are amongst the most urgent of ophthalmic emergencies. The outcome of any chemical burn depends on the concentration and pH of the offending agent and duration of exposure. Alkalis, in particular, cause severe injuries, as they damage cells and penetrate the tissues rapidly. Acid injuries tend to be less severe, as they remain confined to the ocular surface. Mild burns result in loss of the corneal and conjunctival epithelium, which is usually fully recoverable. More severe injuries cause ischaemic damage to the limbal area, which affects the epithelial stem cells that are vital for recovery of the eye. At the initial examination valuable information can be obtained regarding the severity and, thus, prognosis of the injury by evaluating the amount of epithelial loss, the degree of limbal ischaemia and the haziness of the cornea.

In the immediate period after the injury, the rapidity with which treatment is instituted may have an important effect on the final result. This is most pronounced in alkaline chemical burns where every second may count. Immediate, copious irrigation for twenty to thirty minutes of the affected eye with water at the time of the incident may improve the prognosis considerably.

Speed is also vital in penetrating injuries where measures to prevent secondary further loss of intra-ocular tissues from the eye are required. Control of raised intra-ocular pressure after blunt trauma reduces the patient’s pain and prevents secondary corneal and optic nerve damage.

Correct treatment for an eye injury immediately following an accident can prevent loss of sight. It is important to remember that first aid is immediate treatment that is given "first," until experienced medical help is available.