Ophthalmic Emergencies

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OPEN GLOBE INJURIES

CLINICAL DESCRIPTION

Laceration on the cornea or sclera

CLINICAL FEATURESSIGNS AND SYMPTOMS

  • History of injury (always ascertain the mode of injury), reduction/loss of vision following trauma, bleeding from the eye, severe pain, tearing and sensitivity to light, the feeling that there is something in the eye
  • Obvious corneal laceration visible on direct light
  • Prolapsed iris can be seen plugging the laceration
  • Peaked pupil
  • Subconjunctival hemorrhage/hematoma whose posterior limits cannot easily be delineated
  • Anterior chamber is flat +/- hyphema
  • Eyeball is soft

INVESTIGATIONS

  • Examine under topical anesthetic eye drops, gently examine the eye under full aseptic conditions. The laceration will be visible.

TREATMENT

  • Management before referral to a treating centre
    • Tetanus Toxoid (TTV) 0.5ml IM STAT
    • Place plastic shield on affected eye
    • Ceftriaxone 2g IV STAT or Ciprofloxacin 500mg PO 12 hourly for 5 days
    • Give analgesic but preferably avoid NSAIDs to prevent worsening the bleeding 

COMPLICATIONS

  • Retinal detachment
  • Endophthalmitis
  • Glaucoma
  • Traumatic cataract
  • Blindness

REFERRAL CRITERIA 

  • Refer ALL cases to a treating center 

CLOSED GLOBE INJURIES: TRAUMATIC HYPHEMA

CLINICAL DESCRIPTION

This is blood in the anterior chamber as a result of injury

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • History of injury, usually blunt trauma
  • Poor vision
  • Blood clots visible in the anterior chamber.

TREATMENT

  • If a child, admit in hospital and keep under observation. If left unattended, chances of a re-bleed are high resulting in intraocular pressure elevation and corneal endothelial staining
  • If anterior chamber is 1/3 full in an adult, can treat as an outpatient
  • If anterior chamber is >⅓ full, admit the patient
  • Bed rest and bed should be elevated at 45°
  • Dexamethasone 0.1% eye drops 6 hourly
  • Cyclopentolate eye drops 8 hourly for cycloplegia
  • Timolol 0.5% 12 hourly if IOP is elevated or Acetazolamide (Diamox) 250mg PO 8 hourly (remember to ask about renal problems and sulphur allergy before giving acetazolamide)
  • Gentamicin 0.3% eye drops 8 hourly to prevent or treat associated infection
  • Analgesic of preference but avoid NSAIDs

COMPLICATIONS 

  • Corneal endothelial staining
  • Glaucoma

REFERRAL CRITERIA

  • Full chamber hyphema
  • Children with any hyphema
  • Hyphema not improving after 4 days

 

CLOSED GLOBE INJURIES: RETROBULBAR HAEMORRHAGE OR HAEMATOMA

CLINICAL DESCRIPTION

Bleeding in the retrobulbar space. This may be due to ocular trauma or during retrobulbar injections of drugs or anaesthesia and during sinus surgery. This is rare but sight threatening if not managed urgently.

CLINICAL FEATURESSIGNS AND SYMPTOMS

  • History of facial trauma, or periocular interventions
  • Proptosis with or without visual impairment
  • Severe pain which may be associated with nausea or vomiting

INVESTIGATIONS

  • Ultrasonography – visualize the hematoma or active bleeding

TREATMENT

  • Conservative – if mild and minimal risk for vision impairment.
    • Admit patient and raise the head of the bed
    • Digital ocular massage
    • Acetazolamide 250-500mg PO/IV STAT then maintenance of 250mg 6 hourly for 3 days to reduce IOP OR Mannitol 1-2g/kg IV over 30-60 mins to reduce the volume of the vitreous
    • Methylprednisolone 1g IV STAT for neuroprotection
    • Consider adjusting any antithrombotic agents the patient may be on – always discuss with the physicians looking after the patient
  • Surgical
    • Lateral canthotomy and inferior cantholysis

 

CLOSED GLOBE INJURIES: CHEMICAL INJURY

CLINICAL DESCRIPTION

For Chemical injury always treat (see below) and ask questions later. Prognostic features of chemical corneal injuries depend on

  • The pH - alkalis are more damaging than acids
  • Duration of contact
  • Corneal involvement
  • Limbal involvement
  • Associated nonchemical injury such as thermal injury and blunt trauma
  • Conjunctival involvement

TREATMENT

  • Immediate irrigation with water or 2 litres of normal saline until pH is normalized
  • Double evert the upper eye lids and remove any retained particulate matter
  • Repeat pH after 20 minutes, if abnormal repeat the irrigation
  • Daily pH tests, any derangements may indicate the presence of retained chemical particulates and warrants further irrigations and forniceal inspection

Acute management:

  • Use preservative free drugs where possible
  • Preservative free topical antibiotics e.g. 
    • Moxifloxacin 0.3% 6 hourly
  • Topical cycloplegia e.g. Atropine 1% gutt 12 hourly
  • Topical lubricants e.g. Carmellose 1 hourly
  • Oral analgesia

Severe Chemical Injuries

  • Admit
  • Give
    • Topical steroids e.g., Prednisolone 1% 2- 3 hourly for < 10 days
    • Topical ascorbic acid – Sodium Ascorbate 10% 2 hourly for < 10 days
    • Oral Ascorbic Acid 1g every 12hrs
    • Systemic Tetracyclines 100mg 24 hourly for 3 months
    • Acetazolamide 250mg 6 hourly ± Timolol 0.5% 12 hourly
  • Patients need to be counselled for long term follow up to manage complications