Eye Emergencies in the ED

Case #1

History

• 55yo male with PMHx HTN presents with 1 hour of headache and blurry vision starting while at the movie theater associated with nausea and one episode of vomiting

Physical

• Visual Acuity: 20/25 OD, 20/200 OS

Acute angle closure glaucoma

• Symptoms

  • Painful red eye ​

  • Blurry vision​

  • Headache ​

  • +/- N/V​

• Physical findings

  • Increased IOP, > 21 mmHg, usually range from 40-100​

  • Mid dilated non-reactive pupil ​

  • Firm eye on palpation ​

  • Cell/flare in the anterior chamber on slit lamp

• Pathophysiology

  • Severely increased IOP due to the blockage of aqueous circulation from its area of production in the posterior chamber to its area of absorption in the anterior chamber of the eye​

  • often caused by changes in lighting causing pupil dilation blocking aqueous outflow from the anterior chamber

• Treatment

  • Consult ophthalmology ​

  • Do not delay treatment

  • Beta blocker​

    • Timolol drop 0.5% q5-15 min ​

  • Alpha agonist ​

    • Brimonidine drop 0.1-0.2% q5-15 min ​

    • Apraclonidine drop 0.5% q5-15 min ​

  • Acetazolamide IV push 500 mg ​

  • Secondary: ​

    • Mannitol 1-2 g/kg IV infusion over 30 mins​

    • Pilocarpine (cholinergic)​

    • Latanoprost (prostaglandin analog)

  • Goal is to rapidly lower IOP! Can give meds up to 3x titrating to IOP

  • Cases that do not respond to medical management may need to go to the OR for iridotomy

  • Dispo: if IOP lowered and symptoms improved patient can be dc home with drops and ophtho follow up in 24 hours

Case #2

History

• 60yo male with PMHx CAD, HTN, HLD, DM, A fib, presenting with acute painless R sided vision loss just prior to arrival

Physical

• Visual acuity: hand waving OD, 20/30 OS ​

• Intraocular pressure: 22 OD, 15 OS ​

CRAO

• Pathophysiology

  • Ischemic stroke of the retina due to vascular compromise to retinal vessels leading to retinal ischemia and vision loss ​

• Symptoms

  • acute abrupt painless vision loss ​

• Physical findings

  • Exam: decreased VA, APD (paradoxical dilation when light is shone in the affected eye)​

  • Retinal exam: cherry red fovea, pale retina ​

• Treatment:

  • Ocular massage (10-15 sec) ​

  • Timolol drops to reduce production of aqueous humor for elevated IOP ​

  • Acetazolamide for elevated IOP ​

  • Hyperbaric chamber?​

  • Consult ophtho ​

  • Dispo: usually require admission for work up of underlying cause

CRVO

• Pathophysiology

  • Retinal venous rupture leading to diffuse retinal hemorrhage

• Symptoms

  • Acute, subacute, or progressive painless monocular vision loss ​

• Physical findings

  • Exam: Blood and thunder appearance due to retinal hemorrhages, cotton wool spots, APD ​

• Treatment: ​

  • Consult ophtho ​

  • No standard treatment ​

  • Ophtho may suggest laser treatment, operative management ​

  • Lower IOP if elevated ​

  • Most patients can be dc home with ophtho follow up if normal IOP, they will need monthly follow up to monitor disease progression

Retinal Detachment

• Pathophysiology

  • retinal detachment from choroidal layer. Usually secondary to trauma

• Symptoms

  • Monocular painless vision loss with flashes and floaters ​

  • “curtain coming down over vision” ​

  • Hx of myopia, cataract surgery, or trauma are common causes ​

• Physical findings

  • afferent pupillary defect

  • Ophthalmoscopy may reveal vitreous hemorrhage ​

  • Clumped red pigment cells or retinal pigment cell in anterior chamber, “shafer’s sign” ​

• Dx

  • Ultrasound ​

  • Linear probe over eyelid​

• Treatment​

  • Consult ophtho !!​

  • Mac on: urgent surgical intervention within 24 hours can prevent long term visual loss ​

  • Mac off: worse outcomes

Case #3.

History

• 21yo male presenting with decreased vision, eye pain after being punched in the face

Physical

Globe rupture

• Pathophysiology

  • Typically due to blunt or penetrating trauma ​

• Symptoms

  • eye pain, swelling, decreased VA ​

• Physical findings

  • Hyphema ​

  • Positive seidel sign ​

  • Tear drop pupil ​

• Treatment

  • Call ophtho​

  • CT orbits to confirm ​

  • DO NOT TAKE IOP ​

  • Dispo: surgery ​

  • Eye shield while they wait for OR, antibiotics, tdap, elevate HOB, pain control

References

• Hammond Victoria M.. Acute Glaucoma. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recQnDsM14OI8Vjzy/Acute-Glaucoma#h.1kw7ship2r1z. Updated September 20, 2023. Accessed September 25, 2023.​

• Hammond Victoria M. Central Retinal Artery Occlusion. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recZ4EeynOQePRRVU/Central-Retinal-Artery-Occlusion#h.uajzdllpyh2k. Updated May 26, 2022. Accessed September 25, 2023.​

• Hammond Victoria M.. Central Retinal Vein Occlusion. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recyzKgBkkW15r2sA/Central-Retinal-Vein-Occlusion#h.2et92p0. Updated September 8, 2023. Accessed September 25, 2023.​

• Hogrefe Christopher. Retinal Detachment and Defects. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recxCG8B8jJZhZNa9/Retinal-Detachment-and-Defects#h.5wnzimto28t0. Updated August 17, 2022. Accessed September 25, 2023.​

• Joseph Daniel Adrian, Moreira Maria. Eye Trauma. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recewojCaO1wwkLyO/Eye-Trauma#h.g0y4tm97fykz. Updated September 8, 2023. Accessed September 25, 2023.​

• Yoonessi R, Hussain A, Jang TB. Bedside Ocular Ultrasound for the Detection of Retinal Detachment in the Emergency Department. Acad Emerg Med. 2010;17(9):913–917. PMID 20836770

Hayley Scott, MD