Ocular emergencies Erin Moorcones, RN, MSN The Eye Anatomy and physiology The eyes are protected by bony structures, eyelids, and sclera. Lacrimal glands secrete tears, which continuously bathe eye to decrease friction and remove minor irritants. Light enters the eye through the cornea, passes through the lens, and reflected off the retina. Amount of light entering is controlled by iris. Patient Assessment A potential threat to vision is triaged as emergent, whereas patient with a reddened eye with no potential for vision loss could be non-urgent. Visual Acuity Visual acuity should be done on all patients with eye or visual complaint, unless patient sustained chemical exposure to eye where irrigation is priority. Pupil Examination Includes assessment of shape, size, and reactivity. Up to 20-25% of population have unequal pupils ( physiologic anisocoria- pupils vary <1mm with brisk reaction to light) as a normal finding. FYI* oval pupil may indicate tumor or retinal detachment * teardrop pupil suggest ruptured globe- teardrop pointing to rupture site Anterior segment Composed of sclera, conjunctiva , cornea, anterior chamber, iris, lens and ciliary body. Inspect clearness of cornea. • Ocular movement• assess cranial nerves General strategy HPI * Pain- PQRST * Appearance of eye- swelling, redness, aysmmetry * changes in vision, tearing, itching, discharge PMH*pre-existing disease- DM, htn, sicle cell * ocular- lenses, surgery, glaucoma, eye disease Pysch/ social* work environment, school, hobbies Assessment Consultation required Age related considerations Geriatric considerations Vision gradually dimishes until age 70, then rapidly Decreased accuracy of visiontesting Eye accomodation decreases with age Older adults complain of eye dryness. Cataracts more common with advancing age. 1 in 3 adults age 80 affected. More liekly to experience glaucoma, detached retna, retinal bleeding PEARLS* health referrals * Protected environment Infections Lid infectionsHordeolum- infection of eyelash oil gland. Apply warm compress 4 times a day with ophthalmic antibiotics Chalazion Internal hordeolum caused by chronic inflammation. Patient presents with several weeks of painless, localized swelling. If it affects vision may have I&D Herpes Simplex of eye Conjunctivitis Inflammatory condition of membrane that lines the eyelids and covers exposed surface of sclera. Causes- bacteria, virus, chlamydia/gonorrhea, chemical burns, foreign bodies,exposure to irritants. Assessment HPI -redness, abrupt onset, unilateral/bilateral, pain, FB sensation, discharge, edema, itching, burning, fever PMH -URI, contact with others, medications (steroidsmay exacerbate infections, esp w/Herpes infections) Objective data-distress, visual acuity, cornea, pupil, conjunctiva, chemosis, discharge, eyelid edema Assessment Diagnosticculture, fluorescein stain, gram stain Interventions - cleanse eyelids (inner-outer) - warm compress, bacterial/cool compress, viral - medications - education Anterior Uveitis/Iritis Uveitis-inflammation of one or all the parts of the uveal tract (iris, ciliary body, choroid) S/S- intense unilateral pain, conjunctivitis, edema, lacrimation, photophobia. Posterior uveitis (choroiditis)- rare, seen in CMV infections associated with AIDS TreatmentWarm compress, dark enviornment Topical steroid, Eye rest f/u referral Periorbital/Orbital Cellulitis Key assessment pieces S/S- Temperature, Decreased pupillary reflexes Diagnostic- CT, culture, CBC, LP Treatment- warm compress, excision of abscess, antibiotics, F/u Glaucoma S/S- red eye, pain, HA, bluured vision, photophobia, n/v. Physical exam- decreased visual acuity, corneahazy, steamy, intraocular pressure 40-80, hardness to globe with palpation, Diagnostic- slit-lam, tonometry Treatment- beta antagonists, pilocarpine droops Acute angle-closure glaucoma PACG increases with age and more common in women and eskimo’s and those of Asian decent. Estimated to be the cause of 46% of all cases of irreversible blindness. S/S- severe eye pain, fixed or slightly dilated pupil, foggy appearing cornea, severe headache, complaints of halo’s around lights, diminished peripheral vision Treatment- must decrease IOP quickly Central retinal artery occlusion Sudden, painless, unilateral loss of vision caused by thrombus/emboli Prompt recognition and intervention w/I 1-2 hrs of onset necessary. Treatment- referral ocular hypotensive drops carbon gas for vasodilation Trauma Blunt trauma- caused by MVC, fall, assault Symptoms include- ecchymosis, redness Resolution of bruising usually resolves in 2 weeks. Orbital fractures • Involve the orbital floor and orbital rim • Orbital floor fracture, aka blowout fracture. Direct trauma causes increase in IOP. Orbital contents may herniate into the maxillary or ethmoid sinuses. • Diagnosis- by observation of periorbital ecchymosis, subconjunctival hemorrhage, periorbital edema, upward gaze and diplopia. • CT or MRI • Orbital fractures not emergency unless visual injury or globe injury present Hyphema Bleeding into anterior chamber of eye. Occurs when blood vessels of the iris rupture and leak into the clear aqueous fluid of anterior chamber. Symptoms- pain, photophobia, blurred vision Treatment- beta blockers to dec IOP, mydriatic agents, steroids, pain mgmt, anti emetics Subconjunctival hemorrhage Harmless eye condition that is usually triggered by sneeze, cough, Valsalva. Symptoms- painless, bright red flat patch Usually reabsorbs in 2-3 weeks Globe rupture Foreign Body Most common is dust particle Organic FB have higher incidence of infection. Metallic FB leave rust ring unless removed w/I 12 hours Inert FB do not cause infection, but higher risk for penetration Superficial Trauma Corneal abrasionFB such as contact scratches, abrades, or denudes optical epithelium. Damage to cornea exposes corneal nerves causing tearing, eyelid spasms, and pain. May need topical analgesic to get visual acuity. Assess eyelids to ensure no FB. Diagnosis with fluorescein. Corneal laceration Ophthamolgy consult required. Present similar to corneal abrasion Burns Chemical Burns- from acids, alkalis. copious irrigation needed. • Thermal burns- usually affects eyelids. • Radiation burns- UV or infrared