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Eye Emergencies

A "red eye" is a common presenting symptom. The etiology can be as benign as a subconjunctival hemorrhage or as sight threatening as angle closure glaucoma or endophthalmitis. Most cases of red eye can be diagnosed by examination alone and appropriate treatment instituted. Angle closure glaucoma and endophthalmitis require emergent treatment and possibly surgery.

Ocular Examination

The eye examination can be broken down into the eight parts listed in Table 1.

For both medical and legal reasons, visual acuity should be checked on every patient who presents with an eye problem. This is usually done for distance vision with a standard acuity chart (Snellen) and recorded for first the right eye and then

Red Eye

A red eye can signify a sight-threatening process or a benign self-limited disease. Examination findings which help to separate various etiologies are listed in Table 2.

Common non-traumatic causes of red eye, along with recommended treatments, are listed below. (Traumatic causes are given in a later section.)

Subconjunctival hemorrhage. Usually spontaneous onset with no pain or decreased vision. Exam shows solid, bright red patch on bulbar conjunctiva with sharp borders. If the patient has any history of trauma, look for further injury. Treat by

Allergic reactions. The patient has symptoms of itching, burning, and watering. There is often a history of systemic.

Viral infections (non-herpetic). Patients often have a history of exposure to "pink eye" or concurrent upper respiratory

Preauricular adenopathy

Seen with most viral infections, including herpes simplex. Gonococcus only bacterial conjunctivitis with a preauricular

node.

Membrane

Fibrinous membrane over palpebral conjunctiva most commonly seem with adenoviral or herpetic viral infections,

streptococcus or gonococcus bacterial infections.

Herpes Simplex. This usually presents with pain or foreign body sensation and decreased vision. Exam may show

Bacterial Conjunctivitis.

This presents with a history of yellowish discharge and eyelids mattered together upon awakening. It can be mild to severe. Hyperacute or extremely severe cases of purulent conjunctivitis are often due to gonococcus, which is also the only bacterial conjunctivitis to have preauricular adenopathy. Examination shows

Bacterial Keratitis.

Patients have a history of photophobia, pain, and decreased vision. It is more common in soft contact lens wearers, especially if lenses are worn overnight. The patient may have had a predisposing insult to corneal

Fungal Keratitis. The symptoms are similar to bacterial keratitis. The exam shows a more lacy appearance to the corneal infiltrate and needs to be referred to an ophthalmologist. There is often a history of superficial corneal trauma

Endophthalmitis. History of recent (usually within 48-72 hours) intraocular surgery or trauma. There is usually a sudden decrease in vision to hand motions or light perception levels. Exam shows marked conjunctival injection, discharge, possible eyelid edema, hazy cornea, and marked anterior chamber cellular reaction with hypopyon. The fundus is often

Eyelid Infections (Preseptal Cellulitis). There is a history of spontaneous onset or recent minor lid trauma. Exam shows an erythematous and edematous eyelid. The globe is normal to mildly injected. Vision, extraocular motility, pupils, and optic nerve head are usually normal. Look for a hordeolum (infection around base of eyelash) or chalazion

Orbital Cellulitis. Patients give a history of pain, decreased vision, and possible diplopia. They may have sinusitis (especially ethmoiditis), recent orbital trauma, or recent dental surgery. Examination shows swollen, erythematous lids, mild to severe proptosis, limitation of EOMs, decreased vision, and possible afferent pupillary defect. Workup includes a

Dacrycystitis. Patients give a history of purulent discharge and pain over the medial canthal region. Exam shows edema and erythema over region of the lacrimal sac and often reflux discharge through the puncta with pressure over the

Uveitis or Inflammation of the Uveal tissue (Iris and Choroid). The most common emergent presentation is as iritis. A history of pain, photophobia, and decreased vision is given. Exam shows ocular injection, especially at the corneal

Acute Angle-Closure Glaucoma. Patients usually present with sudden onset of redness, decreased vision, intense pain, possibly nausea, and emesis. This is more common in farsighted patients. Examination shows marked ocular injection, especially at the limbus. The cornea is edematous. The pupil may be mid-dilated and non-reactive. The

Carotid Cavernous Fistula. There are two main types, low flow and high flow. The low flow type is usually found in elderly, hypertensive patients without a history of trauma. They present with a red eye secondary to dilated

Traumatic Visual Loss

Chemical burns. Exposure of the eye to chemicals is a true ocular emergency. Prompt and vigorous lavage is crucial to successful management. IV solutions, such as Ringers or normal saline attached to a large bore IV tubing, can be used

A complete history of the incident with identification of the chemical and duration of exposure prior to irrigation is crucial. (See Table 3.) Acids cause surface proteins to precipitate and coagulate, confining the chemical to the surface of the

Eyelid Lacerations

Trauma to the eyelids and orbit can pose a severe threat to eyesight. The history must include relevant information about blunt vs. sharp objects, type of object, and velocity of the object. Thorough examination of the eyelids, globe, motility, and palpation of the orbital rim is important. Presence of lid lacerations requires careful cleaning of the wound and

Orbital Fractures

If examination of the orbital walls with gentle palpation reveals crepitus, subcutaneous air, or a severe restriction to ocular motility, further evaluation with a CT scan of the orbit is indicated to rule out orbital fractures. Orbital fractures are commonly seen with blunt trauma to the orbit. Careful evaluation of the eye by an ophthalmologist prior to surgery is

Intraorbital Foreign Body

If an orbital foreign body is noted on CT scan or on x-ray, proper history to determine type of foreign body is extremely

Corneal Foreign Bodies

Corneal foreign bodies are the most common workplace injury, accounting for nearly 35% of all eye injuries at the workplace. There is usually a history of grinding wheel work or metal upon metal contact. Thorough examination of the

Intraocular Foreign Bodies

Patients with a history of trauma with a sharp object or high-speed missile are at high risk for corneoscleral laceration and possible intraocular foreign body. Signs, such as a shallow anterior chamber, subconjunctival hemorrhage, hypotony, hyphema, cataract, and decreased vision can all point to a ruptured globe. Orbital CT scans with thin slices

Corneal Abrasions and Erosions

In patients complaining of severe pain, erythema with edema of the eyelids, and photophobia, one must strongly consider corneal abrasion in the differential diagnosis. The patient may indicate a history of trauma, contact lens wear, herpes infection, or acute onset of pain upon awakening. Patients should be evaluated with the slit lamp using both regular light

Conjunctival Lacerations

Sometimes, patients with mild pain, red eye, foreign-body sensation, and a history of trauma will only have conjunctival laceration on careful examination of the globe. Exploration of the site and possible CT scan of the orbit may be indicated

Corneal and Scleral Lacerations

Lacerations of the globe can occur due to blunt trauma, missiles, or sharp objects. The sclera and cornea are usually resistant to blunt trauma but, with sufficient force, scleral rupture can occur. Compressive forces rarely cause rupture at the impact site, but ruptures actually occur at a remote site where the sclera is the thinnest. The sclera is the thinnest at

Traumatic Iritis and Hyphema

The four phases of blunt injury are compression, decompression, overshooting, and oscillations? Anterior-posterior compression results in equatorial expansion, shortening of the visual axis, and posterior displacement of the lens and

If the patient complains of pain, photophobia, and tearing, a careful slit lamp examination must be done to check for

Flare and cell in the anterior chamber indicates traumatic uveitis, which runs a brief and benign course. Cycloplegics drops (Cyclogyl 1% qid) and prednisone drops (Prednisolone acetate 1% qid) for one week will reduce the inflammation

Patients with blood in the anterior chamber or on slit lamp exam have a hyphema. These patients deserve a thorough examination by an ophthalmologist to rule out possibility of a ruptured globe. There is a high risk of rebleed within five days of the initial trauma and elevated intraocular pressures. Historically, patients were hospitalized for hyphema, but

Retinal Edema, Retinal Tears, and Vitreous Hemorrhage

Traumatic forces can cause violent movement of the vitreous away from the retina, resulting in a coup or contrecoup lesion in the retina. Types of injuries most often encountered are retinal tears and nontearing retinal injury resulting in retinal edema or retinal hemorrhages. Retinal edema, called Berlin's edema or commotio retinae, can be seen in the

Lens Subluxation/Dislocation

Compressive forces from trauma can cause dehiscence of zonules supporting the lens. Decentration of the lens with some partial zonular dehiscence is called subluxation. Total zonular disruption can lead to lens dislocation into the

Optic Nerve Trauma

Patients with an injury to the optic nerve may have decreased visual acuity, visual field deficits, or a relative afferent pupillary defect. Examination of the pupils with the swinging flashlight test must be performed, but sometimes because of corneal opacities, hyphema, or lid edema, it is difficult to assess the injured eye. In this instance, checking the

Non-Traumatic Visual Loss

Acute, non-traumatic visual loss presents special diagnostic challenges. Important historical points include time of onset, quality and severity of visual loss, mono- or binocularity, duration of loss, and associated ocular and systemic diseases. It is helpful to think through the globe structure from anterior to posterior to sort out the various etiologies of

Optic Nerve Disorders

Optic nerve dysfunction causes decreased visual acuity, color vision, and almost always presents with an afferent pupillary defect. The optic nerve can appear swollen, congested, and possibly pale, or it can look normal if the insult is retrobulbar. Optic neuritis

Anisocoria

Anisocoria, or a difference in pupil size, can be a benign physiological state or a sign of a serious, life-threatening intracranial disease. Important historical points are any recent trauma, any previously noted anisocoria, any foreign

Diplopia

Diplopia, or double vision, can be separated into binocular diplopia (present only with both eyes open) or monocular diplopia (still present with one of the eyes closed). Other important historical points are time of onset, whether the diplopia is intermittent or constant, directions of gaze in which diplopia worsens, antecedent trauma, and any