What are the common ophthalmic emergencies and their immediate treatments?

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Common Ophthalmic Emergencies and Their Immediate Treatments

Prompt recognition and immediate treatment of ophthalmic emergencies is essential to prevent permanent vision loss and should be initiated before urgent ophthalmology referral. 1

Key Ophthalmic Emergencies

1. Acute Angle-Closure Glaucoma

  • Presentation: Sudden onset of unilateral painful red eye, blurry vision, constitutional symptoms 2
  • Diagnosis: Confirmed by elevated intraocular pressure (IOP) measurement
  • Immediate Treatment:
    • Administer acetazolamide 500mg IV as initial dose followed by 125-250mg every four hours 3
    • Timolol 0.5% eye drops (contraindicated in patients with asthma, bradycardia, heart block, or cardiac failure) 4
    • Brimonidine eye drops (caution: may cause drowsiness, dry mouth, ocular hyperemia) 5
    • Urgent ophthalmology referral for definitive treatment

2. Retinal Detachment

  • Presentation: Sudden onset of floaters, flashes of light, followed by curtain-like shadow in visual field 2
  • Diagnosis: Indirect ophthalmoscopy is preferred
  • Immediate Treatment:
    • Bed rest with affected eye positioned upward
    • Eye shield protection
    • Urgent ophthalmology referral for surgical repair
    • No eye drops or medications are indicated initially

3. Chemical Eye Injuries

  • Presentation: Pain, redness, blurred vision after chemical exposure
  • Immediate Treatment:
    • Immediate copious irrigation with saline or water for at least 30 minutes
    • pH testing of conjunctival fornices
    • Continue irrigation until pH normalizes (7.0-7.4)
    • Urgent ophthalmology referral

4. Globe Rupture/Penetrating Eye Injury

  • Presentation: History of trauma, decreased vision, irregular pupil, shallow anterior chamber
  • Immediate Treatment:
    • Do NOT apply pressure to the eye
    • Rigid eye shield placement (no eye patches)
    • No eye drops or ointments
    • NPO status
    • Antiemetics to prevent increased IOP from vomiting
    • Systemic antibiotics
    • Urgent ophthalmology referral 2

5. Central Retinal Artery Occlusion

  • Presentation: Sudden, painless, profound vision loss
  • Immediate Treatment:
    • Digital ocular massage
    • Anterior chamber paracentesis (by ophthalmologist)
    • Acetazolamide 500mg IV 3
    • Urgent ophthalmology referral
    • Consider thrombolytic therapy within 4.5 hours of onset

6. Endophthalmitis

  • Presentation: Severe eye pain, decreased vision, hypopyon, following eye surgery or trauma
  • Immediate Treatment:
    • Urgent ophthalmology referral for intravitreal antibiotics
    • Systemic antibiotics may be started

7. Orbital Cellulitis

  • Presentation: Eyelid swelling, proptosis, limited extraocular movements, fever
  • Immediate Treatment:
    • IV broad-spectrum antibiotics
    • CT scan of orbits
    • Urgent ophthalmology and ENT referral

8. Corneal Foreign Body/Abrasion

  • Presentation: Foreign body sensation, pain, tearing, photophobia
  • Immediate Treatment:
    • Foreign body removal (if visible and superficial)
    • Antibiotic eye drops
    • Cycloplegic eye drops for comfort
    • Eye patching is generally not recommended
    • Ophthalmology follow-up within 24 hours

Important Considerations

  • Time-Critical Nature: Delay in treatment can result in permanent vision loss, especially in conditions like central retinal artery occlusion (4-6 hour window) and acute angle-closure glaucoma 1

  • Medication Cautions:

    • Timolol is contraindicated in patients with asthma, bradycardia, heart block, or cardiac failure 4
    • Brimonidine can cause significant systemic side effects including drowsiness and should be used with caution 5
    • Acetazolamide dosing for glaucoma differs from its use in other conditions 3

  • Examination Pearls:

    • Visual acuity assessment is the vital sign of the eye
    • Pupillary reactions help identify optic nerve involvement
    • Slit lamp examination is essential for anterior segment evaluation
    • Tonometry for IOP measurement in suspected glaucoma
    • Fundoscopic examination to assess retina and optic nerve

  • Common Pitfalls:

    • Failing to recognize time-sensitive emergencies
    • Removing protruding foreign bodies from penetrating eye injuries
    • Delaying referral for conditions requiring immediate surgical intervention
    • Using topical anesthetics for pain control (can delay healing and mask worsening symptoms)

Ophthalmic emergencies account for approximately 3% of emergency department visits, and while rarely life-threatening, they can lead to significant morbidity including permanent vision loss if not promptly addressed 6.

References

1
Research

Ophthalmic Emergencies for the Clinician.

Mayo Clinic proceedings, 2020

6
Research

Ophthalmologic procedures in the emergency department.

Emergency medicine clinics of North America, 2008

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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