Ophthalmology Emergency Protocols

Ocular surface disturbance/corneal abrasion

• common
• within hours of operation
• discomfort and decreased visual acuity (variable)
• no hypopyon
• some generalised corneal fluorescein uptake or frank corneal abrasion
• discomfort immediately settles with topical local anaesthetic, eg. Proxymethacaine
• Management - Chloramphenicol ointment and reassurance

Post-op iritis

• common
• within days or weeks of operation
• discomfort and mildly decreased visual acuity
• if only mild conjunctival redness, no hypopyon and reasonable view of retina then have excluded endophthalmitis
• Management - review the following day in the Ophth unit

Raised intraocular pressure

• not common
• if only mild conjunctival redness, no hypopyon and reasonable view of retina then check intraocular pressure (IOP) with tonometer (A&E Raigmore)
• if raised (over 30) or can’t check pressure consider start topical glaucoma medication as per Acute Angle Closure Glaucoma protocol (Latanoprost, Timoptol and Iopidine) and arrange review following day in Ophth Unit

Endophthalmitis

• not common
• 1 to 14 days after operation
• severe eye pain
• severe visual loss (usually Counting Fingers only or worse)
• Hypopyon
• Emergency - see separate “Endophthalmitis” section for management

Hyphaema

Following blunt ocular trauma (eg punch, badminton or football injury) a fluid level of blood (hyphaema) may be visible in the anterior chamber between the cornea and the lens.

Management:

1. Topical Steroid (Maxidex) four times per day
2. Mydriatic (Cyclopentolate 1%) three times per day.
3. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.

Depending on the mechanism of injury, there might be a corneal abrasion, and this should be managed as per that protocol.

Blow out fracture

Symptoms:

1. Patient complains of double vision, especially on looking up
2. May have paraesthesia in the distribution of the infraorbital nerve (check, upper lip, plus teeth and gums)

Signs:

1. Restricted upgaze
2. Enophthalmos (affected eye appears further back in orbit)
3. Inferior orbital fracture on Radiology

Management:

1. Refer to Max-Fax service
2. Referral to Ophthalmology plus Orthoptics - that day or, if out of hours, the following day

Retro-orbital Haemorrhage

Trauma can rarely cause an arterial bleed behind the orbital septum which can lead to a rapid onset of swelling of the lids and proptosis. Unless dealt with very quickly there is the risk of irreversible blindness.

Symptoms:

1. Pain
2. Decreased vision (hand movements only or worse)

Signs:

1. Tense lid swelling
2. Tense proptosis
3. Decreased eye movements
4. May be difficult to prise the lids apart to examine the globe - if available the insertion of a speculum following instillation of topical anaesthetic may help.
5. Unresponsive pupil

Management:
Requires immediate lateral canthotomy.

1. Infiltration of local anaesthetic into the lateral lower lid
2. Disinsert lower lid at the lateral end by placing sharp scissors into the lower lid and cutting downward and laterally towards the orbit (ensuring that the orbital septum is penetrated). There should be a release of the orbital blood which will be under pressure. (video at https://first10em.com/lateral-canthotomy/)
3. Admit to 4A

Traumatic Optic Neuropathy

Symptoms:

1. Decreased visual acuity – may be severe, almost always one eye only

Signs:

1. Unresponsive pupil
2. Absence of other eye pathology to explain decreased acuity

Management:

1. Exclude retro-orbital haemorrhage clinically (ie. absence of tense proptosis and decreased eye movements)
2. Analgesia as required
3. Referral to Ophthalmology - that day or, if out of hours, the following morning

N.B There is no evidence for the use of systemic steroid in the management of Traumatic Optic Neuropathy.

Ruptured Globe/Penetrating trauma

Usually result of high impact trauma or sharp trauma, eg. falling whilst intoxicated and striking the eye on a table edge or hammer/chisel injuries.
Symptoms:

1. Pain
2. Decreased vision

Signs:

1. Subconjunctival haemorrhage
2. Hyphaema
3. May have obvious corneal or sclera laceration with prolapsing pigmented tissue

Management:

1. Refer Ophthalmology (out of hours - admit to Ward 4A with review the next morning)
2. Eye shield
3. Nurse propped up
4. Chloramphenicol eye drops 4 times per day
5. IV Ciprofloxacin 400mg twice daily
6. Analgesia
7. Keep nil by mouth from 2am

• Ask about mechanism of injury. If there is a possibility of an orbital foreign body, arrange CT orbits
• Explore depth of wound, check vision and examine ocular surface. If there is a significant ocular injury follow the ocular trauma protocol
• Check tetanus status, give booster if necessary
• Animal bites require broad spectrum oral antibiotics
• Superficial tear to skin
  • Clean and apply steristrips
• Deep laceration
  • Clean and glue or suture with 6/0 nylon (or similar)
  • Refer for routine ophthalmology follow-up
• Any laceration involving the lid margin, any laceration nasal to the punctum in either the upper or lower lid, or if there is extensive tissue loss or distortion of the anatomy
  • Apply chloramphenicol ointment
  • Apply non-stick dressing (such as Gelonet)
  • Apply pad or gauze, and tape tightly
• Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Immediate treatment (and neutralisation of pH)

• Test pH;
• Instill topical anaesthetic (Proxymethacaine,Bupivacaine or Tetracaine),
• Insert a speculum
• Irrigate with at least 2L of Normal saline or water through IV giving set (including into the fornices) until normal pH is restored

Inspection

• Evert the lids (if possible), inspect lids and fornices and remove any particulate material with a cotton bud (e.g. lime, cement)

pH testing

• Test pH at the end of irrigation and 5 min after.
  
  • If pH neutral/near neutral (compare to other eye if necessary), then begin examination and history taking and initiate further treatment (see below). Recheck pH after 20 mins
• If pH abnormal, repeat irrigation cycle with another 2L until pH normal

Examination

• Record visual acuity and pupil reactions
• Look for abnormal whitening of conjunctival vessels adjacent to cornea (limbal ischaemia)
• Check for corneal/conjunctival abrasions with fluorescein

Further treatment

• Topical antibiotics: Preservative free Chloramphenicol eye drops 4 times per day
• Topical cycloplegia: Preservative free Cyclopentolate 1% 3 times per day
• Topical steroids: Preservative free Dexamethasone 0·1% 4 times per day
• Topical lubricants: Preservative free Celluvisc 1% or Xailin gel 6 x a day and Xailin Night ointment at night
• Oral analgesia as required
•  Consider admitting to Ward 4A if severe injury (extensive corneal abrasion and limbal ischaemia)
• Review by Ophthalmologist same day or following morning if out of hours

Endophthalmitis is an intraocular bacterial infection following intraocular surgery or intraocular injection.
Extremely rare - incidence of 1 per year in NHS Highland. Can occur any time from the day after surgery to 2 weeks after surgery (most commonly 3 to 5 days following surgery)
Symptoms:

1. Increasingly severe eye pain
2. Increasingly marked eye redness
3. Rapid and significant decreasing vision (often to hand movements or worse), since the procedure.

There are many conditions that can give pain and redness, eg post-operative iritis, but endophthalmitis is extremely unlikely without a significant drop in vision. Some patients who receive intravitreal injections have poor vision to start with, so it is worth checking with the patient what the vision was like immediately following the procedure. Also, vision following vitrectomy is often vague hand movements due to intraocular gas, which lasts for 2 weeks post-operatively - this is normal.

Signs:

1. Decreased acuity (usually counting fingers or hand movements only)
2. Conjunctival redness
3. Anterior chamber inflammation may give rise to:
   a) Visible difference between visibility of the iris and pupil between the two eyes – affected eye hazy.
   b) Hypopyon (pus level at bottom of anterior chamber - see photograph below)
   c) Poorly reactive pupil

Management:

1. Admit to Ward 4A, Raigmore as soon as possible
2. Intravitreal antibiotics by Ophthalmologist as soon as possible - if you state that your patient has endophthalmitis Raigmore switchboard will put you through to an Ophthalmologist (even out of hours)
3. Ofloxacin eye drops hourly
4. Oral Ciprofloxacin 750mg twice daily
5. Atropine 1% eye drops, 3 times per day
6. Analgesia

Symptoms:
Lid swelling
Decreased vision
Double vision
Feels unwell – often preceding Upper Respiratory Tract Infection

Signs:
Decreased visual acuity
Proptosis
Lid swelling
Conjunctiva red and chemosed
Reduced ocular motility
May have afferent pupillary defect
Pyrexia

Management:

1. Admit under ENT to Ward 4A if adult (Paediatric Ward if a child) for Senior ENT assessment
2. Ophthalmic assessment - visual acuity, colour vision, pupil reactions, ocular motility
3. IV access
4. FBC, U&Es, PV, CRP and blood culture
5. IV antibiotics – Cefotaxime and Flucloxacillin
6. Otrivine nasal drops (not under 2 years old)
7. 4 hourly neuro obs
8. Emergency CT scan of Brain and Orbits if impairment on eye examination
9. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Symptoms:
Pain
Blurred vision
Coloured haloes around lights
Frontal headache
Nausea and vomiting

Signs:
Hazy cornea
Red conjunctiva
Mid-dilated pupil that doesn’t respond to light
Patient usually elderly and long-sighted
Measure intraocular pressure if possible (Ophth nurses on Ward 4A) – pressure will be greater than 35mmHg.

Management:

1. Admit Ward 4A
2. Actetazolamide 500mg IV stat then 250mg orally (or IV) 4 times daily
3. Latanoprost eyedrops once daily, Timoptol 0·25% eyedrops twice daily, Iopidine 1% eyedrop 3 times daily, Pilocarpine 2% 4 times daily - all to affected eye
4. If still pain/vomiting 2 hours after above treatment give Mannitol 10% 500ml IV infusion over 60 minutes unless contraindicated
5. Nurse supine
6. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Corneal infection with overlying ulcer / defect in the corneal epithelium
Causes:

1. Bacterial
2. Viral (Herpes simplex)
3. Others (rare) - Fungal, Acanthamoeba

Risk factors:

• Contact lens use
• Blepharitis (sticky eyelashes, red eyelids)
• Severe dry eye, especially elderly
• Previous Herpes simplex virus of eye or skin

Symptoms

• Red eye
• Watery eye
• Pain – strong foreign body sensation or more severe constant pain
• Photophobia - pain in bright light
• Reduced vision

Signs:

• Use Proxymetacaine local anaesthetic drops to reduce pain and allow examination / swabs
• Grey / white opacity in cornea - typically fairly central rather than at very edge of cornea
• Fluoroscein drops - ulcer stains green in blue light
• Red eye maximal around corneal edge
• Hypopyon (white ‘fluid level’ visible against inferior iris)
• Dendritic ulcer (branching linear pattern) indicates Herpes simplex

Management:

• If Herpes simplex dendritic ulcer - Ganciclovir ointment 5 times daily , review Ophthalmology within 72h
• All other corneal ulcers - treat as bacterial keratitis:
  1. Conjunctival swab for C&S
  2. Corneal swab from ulcer for C&S
  3. If contact lens and / or contact lens case available - send for C&S
  4. Admit to Ward 4A, side room
  5. Ofloxacin drops hourly day and night
  6. Cyclopentolate 1% drops three times a day
  7. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.

Central retinal artery occlusion (CRAO)

Causes of CRAO:

1. Thromboembolic (common)
2. Giant Cell Arteritis (rare)

Symptoms:
Sudden profound loss of vision in one eye
May have had amaurosis fugax in preceding days/weeks
May have history of cardiovascular risk factors.
Painless, white eye

Signs:
Visual acuity: usually only counting fingers or worse.
Relative afferent pupillary defect present
Pale retina (subtle) with cherry red spot at fovea may be visible on fundoscopy

Management:
Must exclude Giant cell arteritis (GCA)  if over 50 years old-

• History of GCA symptoms/ polymyalgia (jaw claudication, etc)
• Raised inflammatory markers PV/ESR, CRP
• Can have raised acute phase proteins, alk phos, Platelets, Gamma-glutamyl transferase
• Can have a normocytic anaemia

1. Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose
2. If no suspicion of GCA arrange for follow up with Ophthalmology that day or, if out of hours, the following day
3. If GCA is clinically suspected:
   • Admit to Physicians
   • 1g IV Methyl Prednisolone as soon as possible
   • Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Central retinal vein occlusion (CRVO)

Symptoms:
Sudden loss of vision in one eye (can be mild - severe)
May have history of cardiovascular risk factors
Painless, white eye

Signs:
May have relative afferent pupillary defect
Retinal flame shaped haemorrhages may be visible on fundoscopy

Management:

1. Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose, TFTs
2. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.

Anterior ischaemic optic neuropathy (AION)

Symptoms:
Sudden loss of vision or visual field in one eye
Visual field defect
May have had amaurosis fugax in preceding days/weeks
Check for symptoms of GCA (jaw claudication, etc)
White eye

Signs:
May have altitudinal visual field defect (loss of either top half or bottom half of visual field)
Will have afferent pupillary defect
Swollen pale disc + disc haemorrhages on fundoscopy

Management:
Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose
Must exclude Giant cell arteries if over 50 years old

• If history of GCA symptoms/ polymyalgia
• Raised inflammatory markers PV/ESR CRP
• Can have raised acute phase proteins alk phos, Platelets, Gamma-glutamyl transferase
• Can have a normocytic anaemia

If GCA is clinically suspected:

1. Admit to Physicians
2. 1g IV Methyl Prednisolone as soon as possible
3. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Amaurosis fugax

Symptoms:
Sudden transient unilateral loss of vision – usually lasts secs-mins
May have a history of cardiovascular disease or known risk factors
Painless, white eye

Signs:
Normal vision and visual field
No afferent pupillary defect

Management:
Follow up to date TIA protocol
Refer to Neurovascular Clinic by email
NB GCA can occasionally present as amaurosis fugax – check for
consistent history
Must exclude Giant cell arteries if over 50 years old

• If history of GCA symptoms/ polymyalgia
• Raised inflammatory markers PV/ESR CRP
• also can have raised acute phase proteins alk phos, Platlets, Gamma-glutamyl transferase
• can have a normocytic anaemia

If GCA is clinically suspected

1. Admit to Physicians
2. 1g IV Methyl Prednisolone as soon as possible
3. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Macular Haemorrhage

Symptoms:
Sudden unilateral central loss of vision (but with preserved peripheral visual field)
Painless, white eye
May have recent preceding history of distortion of central vision
May have a history of macular degeneration

Signs:
Reduced visual acuity
No afferent pupillary defect
Haemorrhage seen at macula (central retina) on fundoscopy

Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Vitreous haemorrhage

Symptoms:
Progressive loss of vision or shadow in one eye
Floaters may be present
Painless, white eye
Often have a history of diabetic retinopathy or previous retinal vein occlusion

Signs:
Reduced vision (variable degree)
No afferent pupillary defect
No red reflex on ophthalmoscopy
No view of retina on ophthalmoscopy

Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Retinal detatchment

Symptoms:
Progressive loss of vision or shadow in one eye
Flashing lights and floaters.
Painless, white eye
May have a history short sightedness, or blunt trauma
May have a family history of retinal detachment

Signs:
Vision may be reduced (variable)
Visual field defect may be present
Afferent pupillary defect may be present
May see detached retina on ophthalmoscopy

Management:
Position on back
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

NB. If flashes and floaters but no loss of vision or visual field then refer non-urgently by email

Optic Neuritis

Symptoms:
Gradual reduced vision in one eye
Pain behind eye on eye movement
May have history of MS or other neurological symptoms

Signs:
Reduced visual acuity in affected eye (variable)
Desensitivity to colour red on comparison with fellow eye
Relative afferent pupillary defect
Optic nerve may be swollen or normal on ophthalmoscopy

Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Functional visual loss

Diagnosis of exclusion
Common in children
Suspect when poor vision is reported but visual behaviour doesn’t support this
Ensure there is no relative afferent pupillary defect

Management:
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Migraine

Symptoms:
Transient visual disturbance then returns to normal
Unilateral or bilateral
Typically lasts 15 to 20 minutes
May describe strobing, zig-zags or kaleidoscope effects
May be followed by headache
May have previous migraine history 

Signs:
Normal examination once settled

Management:
Reassurance
No follow up normally required

Foreign body: corneal/conjunctival/subtarsal

Symptoms:
Pain, foreign body sensation, decreased vision, watering

Signs:
Foreign body visible on cornea or conjunctiva, linear corneal
abrasions with fluorescein (subtarsal foreign body

Management:
Topical anaesthetic: Proxymethacaine drops
Evert lid if subtarsal
Remove foreign body if possible

If foreign body removed:
Chloramphenicol ointment 4 times daily for 5 days
Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home
Oral analgesia as required
Discharge

If can’t remove foreign body:
Chloramphenicol ointment 4 times daily for 5 days
Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home
Oral analgesia as required
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.

Corneal abrasion

Symptoms:
Pain and photophobia, watering, decreased vision

Signs:
Corneal epithelial disturbance (but no corneal opacity) which stains well with fluorescein, red conjunctiva

Management:
Chloramphenicol ointment 4 times daily for 5 days
Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home
Oral analgesia as required
Discharge

Arc eye

Symptoms:
Few hours after welding (or sunbed use)
Pain and photophobia, watering, decreased vision

Signs:
Red conjunctiva, mild corneal haze, diffuse punctuate corneal staining with fluorescein

Management:
Chloramphenicol ointment 4 times daily for 5 days
Analgesia: Topical Cyclopentolate 1% stat then Topical Diclofenac pack to take home
Oral analgesia as required
Discharge

Conjunctivitis

Symptoms:
Itching, burning, gritty, watery or discharging eyes

Signs:
Red and oedematous lids and conjunctiva, discharge on lashes

Management:
Conjunctival swab if possible
Chloramphenicol ointment 4 times daily for 5 days
Liquifilm tears 4 times daily for lubrication if required
Oral analgesia as required
Discharge

Iritis

Symptoms:
Increasing pain and especially photophobia, decreasing vision

Signs:
Red conjunctiva - especially adjacent to corneal limbus
Check cornea is normal (including with fluorescein) to exclude a corneal ulcer

Management:
Predforte or Maxidex hourly during day
Cyclopentolate 1% 3 times daily
Oral analgesia as required
Ophthalmology review in clinic within 3 days – refer by email

Sub-conjunctival haemorrhage

Symptoms:
If no trauma involved usually asymptomatic, sometimes foreign body sensation

Signs:
Blood under conjunctiva obscuring underlying sclera

Management:
Liquifilm tears 4 times daily for lubrication if required
Discharge