Eye Problems
Eye
problems seen in the Emergency Department are usually the result of trauma
affecting the anterior part of the eye, but can also be manifestations of
systemic, CNS or vascular disorders.
A brief general history should
include details of diabetes, stroke, hypertension, neurological or cardiac
problems and drug treatment. Ask about trauma and the use of hand or power
tools prior to the symptoms, as shards of metal or ceramic material are common
foreign bodies.
Ask about previous eye problems
including treatment, and corrective lenses if worn. If vision is impaired, was
the deterioration sudden or gradual?
Examination
Topical anaesthetic drops are
necessary if the eye is painful. Check the label carefully as different eye
drops are often stored together. Any eye that has had topical anaesthesia must
be padded until painful again, to protect the eye while normal protective
reflexes are lost. Never give the patient anaesthetic drops to take home.
•
Visual
acuity must be recorded for every patient (use glasses if worn, pinhole if
glasses not available).
•
Examine
the skin around the eye and
evert the eyelids to check for foreign bodies.
•
Visual
fields are particularly
important when retinal or cerebrovascular disease is suspected.
• Eye
movements should be tested
and feelings of double vision sought. Nystagmus and conjugate eye movements are
indicative of cerebellar and brainstem function.
•
Pupils
should be examined for size,
symmetry and reaction to light.
•
Ophthalmoscopy
is necessary if there is
loss of visual acuity.
Slit lamp examination
The slit lamp illuminates and
magnifies the cornea and the anterior chamber of the eye. Fluorescein dye makes
corneal abnormalities fluoresce yellow-green in ultraviolet light. Intraocular
pressure measurement is essential if there is any possibility of glaucoma.
Common diagnoses
Corneal abrasion or foreign body
Foreign bodies embedded in the
cornea are usually caused by use of power tools without eye protection. The
patient presents with a red, painful, watering eye, and the foreign body is
usually easily visible. Use fluorescein to show corneal damage.
Use topical anaesthesia and
remove the foreign body and any rust ring scraping with a dental burr or the
side of a needle bevel (mount the needle on a syringe barrel to aid
manipulation). Treat with antibiotic ointment, which lubricates and protects
the healing cornea, and arrange review in 36–48 hours, to assess healing and
check for missed foreign body or residual rust.
Welder’s arc/flashburn
Electrical arc welding generates
intense ultraviolet light. If a dark glass shield is not used, severe bilateral
pain and redness develops several hours later. Fluorescein reveals corneal
inflammation with tiny dots of fluorescence. Treatment is systemic analgesia
and protection/padding of the eyes for the 2–3 days it takes to resolve.
Conjunctivitis
The patient presents with red
eyes with watery discharge, usually bilateral, and associated with normal
visual acuity. The cause may be one of the following.
• Viral:
most common, sometimes after
an upper respiratory tract infection, very transmissible; advise the patient to
wash hands and avoid sharing towels, but no treatment is necessary.
• Allergic:
advise the patient to use
topical and systemic antihistamines available from pharmacies.
• Bacterial:
rapid onset, purulent –
consider Gonococcus or
Chlamydia.
Conjunctivitis should improve
within 10 days; if not, an ophthalmology review is necessary.
Subconjunctival haemorrhage
This dramatic appearance is
caused by rupture of a subconjunctival vein and spread of blood below the
conjunctiva. No treatment is necessary unless it occurs in the context of head
injury, when it indicates a skull base fracture.
Diagnoses not to miss
Globe rupture
If globe rupture is suspected, a
ring bandage is placed around the eye to prevent any pressure on the globe.
Intravenous antibiotics, analgesics and anti-emetics are given: urgent CT and
refer.
Intra-ocular foreign body
Suspect if there is the feeling
of a foreign body and the possibility of high-energy material, yet little or no
corneal damage. Urgent CT and refer.
Acute angle closure glaucoma
Rare below 60 years of age, this
presents with pain, headache, blurred vision with haloes around lights, and
nausea. The eye is red, feels firm, and there is a mid-sized irregular
unreactive pupil.
High intraocular pressure
confirms the diagnosis: treatment is intravenous
acetazolamide and urgent referral.
Giant cell arteritis
Occurring in the elderly, rapid
visual loss is associated with head- ache, jaw claudication (pain on chewing),
tender temporal arteries and a pale and swollen optic disc on fundoscopy. An
erythrocyte sedimentation rate (ESR) >50 is likely, but the gold standard for diagnosis is temporal artery
biopsy. Commence high-dose steroids immediately and refer.
Dendritic ulcer
These branching ulcers, caused by
herpes simplex virus (HSV) infection are best seen with fluorescein, but can be
mistaken for abrasions. Treat with topical antivirals and refer.
Orbital floor (blowout) fracture
Patients with a facial fracture
should be checked for an upward gaze palsy by holding the patient’s head still
and moving a finger upwards 50 cm from the face. Diplopia suggests tethering of
the inferior rectus muscle/soft tissue, preventing upward gaze, and need for referral.
Central retinal artery/vein occlusion
Central retinal artery occlusion
(CRAO) causes sudden painless loss of vision, with a pale fundus except
for a red macular spot, and is caused by emboli, atherosclerosis or giant cell
arteritis. Central retinal vein occlusion (CRVO) is similar, but of slower
onset, and is associated with diabetes and hypertension, giving swollen
oedematous retinal vessels. Immediate referral is necessary for both.
Transient ischaemic attack
Patients with a transient
ischaemic attack (TIA) affecting their visual cortex describe ‘a curtain coming
down’ on their vision – sometimes known as amaurosis fugax (Chapter 42).
Retinal detatchment
Retinal detachment presents with
gradual visual deterioration, floaters, flashes or field defects in middle-aged
or myopic patients or in patients with diabetes. Opthalmoscopy in the Emergency
Department cannot detect all cases of retinal detachment, so consider
ultrasound and refer.
Ophthalmic varicella zoster virus
Shingles affecting the trigeminal
nerve can manifest with pain or sensory symptoms, which precede the vesicular
rash. Treat with oral acyclovir and refer.
Orbital cellulitis/endophthalmitis
Any suspicion of infection in the
orbit needs antibiotics, CT and referral. Pain on eye movement indicates deep
infection.
Acute inflammatory eye conditions
A number of conditions can
present with painful visual disturbance, and red eyes. These differ from
conjunctivitis in that visual acuity
is not normal, and referral is necessary.
