Eye problems seen in the Emergency Department are usually the result of trauma affecting the anterior part of the eye, but can also be manifestations of systemic, CNS or vascular disorders.
A brief general history should include details of diabetes, stroke, hypertension, neurological or cardiac problems and drug treatment. Ask about trauma and the use of hand or power tools prior to the symptoms, as shards of metal or ceramic material are common foreign bodies.
Ask about previous eye problems including treatment, and corrective lenses if worn. If vision is impaired, was the deterioration sudden or gradual?
Topical anaesthetic drops are necessary if the eye is painful. Check the label carefully as different eye drops are often stored together. Any eye that has had topical anaesthesia must be padded until painful again, to protect the eye while normal protective reflexes are lost. Never give the patient anaesthetic drops to take home.
• Visual acuity must be recorded for every patient (use glasses if worn, pinhole if glasses not available).
• Examine the skin around the eye and evert the eyelids to check for foreign bodies.
• Visual fields are particularly important when retinal or cerebrovascular disease is suspected.
• Eye movements should be tested and feelings of double vision sought. Nystagmus and conjugate eye movements are indicative of cerebellar and brainstem function.
• Pupils should be examined for size, symmetry and reaction to light.
• Ophthalmoscopy is necessary if there is loss of visual acuity.
Slit lamp examination
The slit lamp illuminates and magnifies the cornea and the anterior chamber of the eye. Fluorescein dye makes corneal abnormalities fluoresce yellow-green in ultraviolet light. Intraocular pressure measurement is essential if there is any possibility of glaucoma.
Corneal abrasion or foreign body
Foreign bodies embedded in the cornea are usually caused by use of power tools without eye protection. The patient presents with a red, painful, watering eye, and the foreign body is usually easily visible. Use fluorescein to show corneal damage.
Use topical anaesthesia and remove the foreign body and any rust ring scraping with a dental burr or the side of a needle bevel (mount the needle on a syringe barrel to aid manipulation). Treat with antibiotic ointment, which lubricates and protects the healing cornea, and arrange review in 36–48 hours, to assess healing and check for missed foreign body or residual rust.
Electrical arc welding generates intense ultraviolet light. If a dark glass shield is not used, severe bilateral pain and redness develops several hours later. Fluorescein reveals corneal inflammation with tiny dots of fluorescence. Treatment is systemic analgesia and protection/padding of the eyes for the 2–3 days it takes to resolve.
The patient presents with red eyes with watery discharge, usually bilateral, and associated with normal visual acuity. The cause may be one of the following.
• Viral: most common, sometimes after an upper respiratory tract infection, very transmissible; advise the patient to wash hands and avoid sharing towels, but no treatment is necessary.
• Allergic: advise the patient to use topical and systemic antihistamines available from pharmacies.
• Bacterial: rapid onset, purulent – consider Gonococcus or
Conjunctivitis should improve within 10 days; if not, an ophthalmology review is necessary.
This dramatic appearance is caused by rupture of a subconjunctival vein and spread of blood below the conjunctiva. No treatment is necessary unless it occurs in the context of head injury, when it indicates a skull base fracture.
Diagnoses not to miss
If globe rupture is suspected, a ring bandage is placed around the eye to prevent any pressure on the globe. Intravenous antibiotics, analgesics and anti-emetics are given: urgent CT and refer.
Intra-ocular foreign body
Suspect if there is the feeling of a foreign body and the possibility of high-energy material, yet little or no corneal damage. Urgent CT and refer.
Acute angle closure glaucoma
Rare below 60 years of age, this presents with pain, headache, blurred vision with haloes around lights, and nausea. The eye is red, feels firm, and there is a mid-sized irregular unreactive pupil.
High intraocular pressure confirms the diagnosis: treatment is intravenous acetazolamide and urgent referral.
Giant cell arteritis
Occurring in the elderly, rapid visual loss is associated with head- ache, jaw claudication (pain on chewing), tender temporal arteries and a pale and swollen optic disc on fundoscopy. An erythrocyte sedimentation rate (ESR) >50 is likely, but the gold standard for diagnosis is temporal artery biopsy. Commence high-dose steroids immediately and refer.
These branching ulcers, caused by herpes simplex virus (HSV) infection are best seen with fluorescein, but can be mistaken for abrasions. Treat with topical antivirals and refer.
Orbital floor (blowout) fracture
Patients with a facial fracture should be checked for an upward gaze palsy by holding the patient’s head still and moving a finger upwards 50 cm from the face. Diplopia suggests tethering of the inferior rectus muscle/soft tissue, preventing upward gaze, and need for referral.
Central retinal artery/vein occlusion
Central retinal artery occlusion (CRAO) causes sudden painless loss of vision, with a pale fundus except for a red macular spot, and is caused by emboli, atherosclerosis or giant cell arteritis. Central retinal vein occlusion (CRVO) is similar, but of slower onset, and is associated with diabetes and hypertension, giving swollen oedematous retinal vessels. Immediate referral is necessary for both.
Transient ischaemic attack
Patients with a transient ischaemic attack (TIA) affecting their visual cortex describe ‘a curtain coming down’ on their vision – sometimes known as amaurosis fugax (Chapter 42).
Retinal detachment presents with gradual visual deterioration, floaters, flashes or field defects in middle-aged or myopic patients or in patients with diabetes. Opthalmoscopy in the Emergency Department cannot detect all cases of retinal detachment, so consider ultrasound and refer.
Ophthalmic varicella zoster virus
Shingles affecting the trigeminal nerve can manifest with pain or sensory symptoms, which precede the vesicular rash. Treat with oral acyclovir and refer.
Any suspicion of infection in the orbit needs antibiotics, CT and referral. Pain on eye movement indicates deep infection.
Acute inflammatory eye conditions
A number of conditions can present with painful visual disturbance, and red eyes. These differ from conjunctivitis in that visual acuity is not normal, and referral is necessary.