When is ocular hemorrhage an emergency?

From the Guidelines

Eye hemorrhage is an emergency requiring immediate medical attention when it causes sudden vision changes, severe eye pain, or follows trauma, as it can lead to permanent vision damage or indicate a life-threatening condition, such as a stroke or cerebral hemorrhage, as highlighted in the 2020 study on retinal and ophthalmic artery occlusions 1. When considering the management of eye hemorrhage, it is crucial to prioritize the patient's morbidity, mortality, and quality of life. The 2018 study on the management of acute retinal ischemia emphasizes the importance of prompt diagnosis and treatment, as the risk of stroke is maximum within the first few days after the onset of visual loss 1. Some key indicators that eye hemorrhage is an emergency include:

• Sudden vision loss or changes
• Severe eye pain
• Trauma to the eye
• Floaters, flashes of light, or a curtain-like shadow across the vision, which may indicate retinal detachment or severe bleeding
• Head trauma with eye bleeding, chemical exposure, or eye hemorrhage accompanied by severe headache, nausea, or vomiting The 2024 American Heart Association and American Red Cross guidelines for first aid also recommend seeking immediate medical attention for high-velocity eye injuries, penetrating eye injuries, or eye bleeding after trauma 1. In terms of treatment, prompt referral to a stroke center or emergency department is crucial, as silent brain infarction is a frequent finding in patients with acute retinal arterial ischemia, and these patients are at high risk for future stroke 1. Therefore, it is essential to seek emergency care if any concerning symptoms are present, as prompt treatment can significantly improve outcomes and reduce the risk of permanent vision damage or life-threatening complications.

From the Research

Definition of Ophthalmic Emergencies

• Ophthalmic emergencies are immediate threats to the visual system that can lead to permanent loss of visual function if left untreated 2.
• These emergencies should be detected by physicians and immediately treated and referred to an ophthalmologist if necessary 2.

Identification of Vision-Threatening Pathologies

• Primary care physicians must be able to quickly identify vision-threatening pathologies, as delay in treatment of an ocular emergency can result in permanent vision loss 3.
• Vision-threatening pathologies include blunt ocular trauma, chemical ocular injury, orbital cellulitis, endophthalmitis, acute angle closure glaucoma, optic neuritis, giant cell arteritis, central retinal artery occlusion, retinal detachment, and homonymous hemianopia 3.

Eye Hemorrhage as an Emergency

• There is no direct evidence in the provided studies that specifically states when an eye hemorrhage is considered an emergency.
• However, retinal tears and vitreous hemorrhage are mentioned as potential complications of acute posterior vitreous detachment, and patients taking oral anticoagulants are more likely to present with vitreous hemorrhage 4.
• Retinal tears are commonly found in eyes with acute posterior vitreous detachment and vitreous hemorrhage, highlighting the importance of prompt evaluation and treatment 4.

Management of Ophthalmic Emergencies

• The management of ophthalmic emergencies, including those that may involve eye hemorrhage, requires prompt recognition and treatment by physicians and referral to an ophthalmologist if necessary 2, 3.
• Acetazolamide, a carbonic anhydrase inhibitor, may be used to lower intraocular pressure and increase retinal blood flow, potentially limiting optic disc and retinal ischemia in certain conditions 5, 6.