What to know for eye emergencies

Young Mi Choi, MD
Department of Emergency Medicine, Sejong General Hospital
and Cardiovascular Institute, Sosabon 2-Dong, Sosa-Gu, Bucheon-Si, Gyeonggi-Do, Korea

Vision is a very important sense to all human beings and enables them to function well in their
fields of life. So, it will be disastrous for all of us to lose vision. For this reason, it is vital for
emergency physicians who contact patients primarily to have a sound knowledge of the eye
emergencies. Prompt recognition and appropriate treatment of vision-threatening eye diseases
are essential in the emergency setting when the outcome may depend on timely management.
Ocular emergencies, including acute angle-closure glaucoma, chemical burns, retinal
detachment, orbital cellulites, central retinal artery occlusion, acute corneal abrasions, and
foreign body, are discussed here. And several ophthalmologic procedures are introduced in each
disease entity. They include visual acuity testing, visual field testing, slit lamp examination,
transillumination test, tonometry, lid eversion, fluorescein examination, ocular ultrasonography,
and anterior chamber paracentesis. Careful eye examination and these tests will help emergency
physicians make proper decisions about treatment.
Acute angle closure glaucoma results from pupillary block in which pupillary dilation results
in obstruction of aqueous outflow, accumulation of aqueous in the posterior chamber, and a
rapid elevation in intraocular pressure. Patients complain of severe nausea and vomiting, ocular
pain, headache, and blurred vision. On presentation, the eye will be injected, the cornea
edematous or hazy in appearance, and the pupil mid-dilated and fixed. An intraocular pressure
of the affected globe can be measured by tonometry. A narrow anterior chamber angle,
predisposing to acute angle closure glaucoma, can be confirmed by the transillumination test.
Permanent visual loss can occur if untreated. Intraocular pressure can be reduced by decreasing
aqueous production or increasing aqueous outflow through medical therapy. Definitive surgical
therapy may be necessary in severe cases.
Ocular chemical burns, largely work-related, require rapid treatment. Immediate and copious
irrigation is essential to visual prognosis. In mild chemical burns, the eye will be hyperemic, the
conjunctiva swollen, and the cornea hazy in appearance. Acid burns produce a coagulative

necrosis, so the deeper structures may be protected from further injury. Alkali burns induce a
liquefactive necrosis, disrupt the normal barriers of cornea, and lead to further penetration.
Using litmus paper, we can check the PH of ocular surface. The goal of irrigation is to return the
PH level to normal. Following adequate irrigation, complete ophthalmologic examination is
required to rule out any corneal injuries, retained foreign bodies, or others. Patients should
receive a tetanus prophylaxis, topical antibiotics, and analgesics. Hospitalization may be needed
in severe cases, especially from alkali exposure.
Recent onset of flashes and floaters may indicate retinal detachment. Retinal detachment
results when the retina separates from the underlying retinal pigment epithelium. Among three
types of retinal detachment, rheumatogenous is the most common type. As persons age, the
vitreous shrinks, vitreoretinal traction develops, and retinal tear and detachment result. Risk
factors include older age, previous eye surgery or trauma, diabetic retinopathy, and myopia. The
direct ophthalmoscope is useful to detect an altered red reflex, but its view is too narrow to
exclude a diagnosis of retinal detachment. The indirect examination techniques improve
visualization of the peripheral fundus. Ocular ultrasound detects retinal detachment and is
particularly useful in children and uncooperative patients, and when the view to the retina is
obscured by edema, blood, or other opacities. Surgical correction of retinal detachment,
including scleral buckling techniques, posterior vitrectomy, and pneumatic retinopexy, relives
vitreoretinal traction and close retinal tears.
Orbital cellulites is a potentially life threatening condition, because it may lead to serious
complications such as vision loss, meningitis, cavernous sinus thrombosis, and sepsis. The most
important predisposing factor is sinusitis. In addition, dental problems and trauma are also
important factors. Patients may present with significant pain, swelling, and even proptosis.
Staphylococcal species are the most common pathogen, but other gram-positive organisms and
Pseudomonas should be considered when starting antibiotics. The presence of proptosis, a
dilated pupil, or vision loss results a worse prognosis. CT scan can define the limits of infection
and the presence of an abscess. Admission and emergency ophthalmologic consultation are
warranted.
Central retinal artery occlusion is considered to be an acute stroke of the eye and results in a
sudden painless loss of vision. Most CRAOs are caused by thromboembolism in the central
retinal artery. Typical symptoms include sudden, painless, severe, and persisting loss of vision in
one eye. The pupil may be dilated with sluggish reaction to light. Fundoscopic examination
reveals interrupted columns of blood within the retinal vessels and retinal pallor secondary to

retinal edema, with a characteristic cherry-red spot at the fovea and attenuation of the retinal
arteries. An embolus in a retinal vessel may be seen. Risk factors include old age,
atherosclerosis, diabetes, endarteritis, glaucoma, high cholesterol levels, hypertension,
hypercoagulable states, and migraine. Treatment includes ocular massage, anterior chamber
paracentesis, physical exercise, and medication-induced reduction of intraocular pressure.
Thrombolysis, local intra-arterial fibrinolysis, and other surgical treatment can be recommended.
Eye pain after a trauma caused by a foreign body, rubbing, or a scratch suggests a corneal
abrasion. Patients complain of tearing, pain with eye movement, headache, blurred vision, and
foreign body sensation. Corneal abrasion may also be related with contact lens. On examination,
visual acuity may be normal, and there may be blepharospasm and conjunctival injection of the
affected eye. The flourescein examination is used to detect defects in the corneal epithelium.
Defects will show up as bright green under a blue light on the slit lamp or with a Woods lamp.
Primary goals of therapy are pain control, prevention of infection, and rapid healing of the
corneal epithelium. For treatment, topical NSAIDs, topical antibiotics, cycloplegics, oral
analgesics can be used. Eye patching has no benefit in pain relief and corneal healing.
Foreign bodies are common with corneal abrasions. Minor irritants can be removed by
irrigating the eye and superficial foreign bodies by using a cotton tipped swab. Lid eversion is
helpful for inspecting the tarsal conjunctiva and fornices. Foreign bodies embedded deeper into
the cornea require removal with a hypodermic needle and using a slit lamp. Topical NSAIDs, a
cycloplegic, topical antibiotics and a tetanus booster may be given. Patching is not generally
recommended. Topical steroids, which may promote fungal infection, should be avoided.
Topical anesthetics should also be avoided, because these agents may hide pain associated with
retained foreign body or corneal ulceration.