Chapter 8. Ophthalmology

Clinical Summary

Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. Infection may involve all the orbital structures, including extraocular muscles, sensory and motor nerves, and the optic nerve. Patients present with a moderate to severely inflamed painful eye, conjunctival infection, swelling of the eyelids, and chemosis (conjunctival swelling). As infection progresses, swelling increases and the eye becomes more chemotic and proptotic. Eye movement is diminished in some areas of gaze, or in severe cases, all areas of gaze (frozen globe). Patients are usually febrile and appear to be in acute distress. Orbital cellulitis may occur as a progression from preseptal cellulitis (a much more benign condition) or originate from untreated or undertreated infections of deep skin or paranasal sinuses. Causative pathogens include Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Streptococcus pyogenes, and anaerobes (Peptostreptococcus, Bacteroides, Fusobacterium) depending on the source of infection. Differential diagnosis includes preseptal cellulitis, idiopathic orbital inflammatory pseudotumor, thyroid orbitopathy, dacryocystitis, dacryoadenitis, and trauma with retrobulbar hemorrhage.

Emergency Department Treatment and Disposition

Orbital cellulitis is a true medical emergency particularly in advanced cases when extension posteriorly to the brain can occur and cause rapid deterioration in the patient’s status. Evaluate the orbit and paranasal sinuses with neuroimaging (CT scan with contrast or MRI). Admit patient and obtain prompt ear, nose, throat (ENT); infectious disease; and ophthalmologic consultations in the ED once the diagnosis of orbital cellulitis is considered. If a subperiosteal abscess is noted on imaging, refer promptly to oculoplastic surgery for possible drainage. Begin broad-spectrum intravenous (IV) antibiotics (eg, vancomycin plus either ceftriaxone or piperacillin and tazobactam [Zosyn] or sulbactam and ampicillin [Unasyn]) as soon as possible. Surgical intervention may be needed. If there is an extension posterior to the orbit, admit to ICU.

Pearls

1. Diminished vision can rapidly progress if the orbital process does not respond to treatment; this is a poor prognostic sign.

2. Orbital cellulitis can be life-threatening if infection spreads to the cavernous sinus.

3. If sinus infection is the source, ENT evaluation with surgical drainage may be indicated.

The authors acknowledge the special contributions of Mert Erogul, MD, and Binita R. Shah, MD, to prior edition.

Clinical Summary

Preseptal cellulitis is infection and inflammation anterior to the orbital septum and confined to periorbital soft tissues and eyelids. The globe and orbital structures posterior to the septum are not infected; thus, pupillary reaction, visual acuity, and ocular motility should not be affected. Sinusitis is the most common cause of preseptal cellulitis; other causes include local skin abrasions, hordeolum, or insect bites. Common pathogens are S pneumoniae, S aureus, S pyogenes, and H influenzae (nonimmunized children). Patients present with eyelid swelling, erythema, tense edema, warmth, and tenderness. Tense edema may cause eye closure and the patient may be unable to open the eye spontaneously. Low-grade fever is often present. Differential diagnosis includes orbital cellulitis, allergic conjunctivitis, contact dermatitis, chalazion/hordeolum, necrotizing fasciitis, viral conjunctivitis with secondary eyelid swelling, idiopathic orbital inflammation, thyroid ophthalmopathy, dacryoadenitis, dacryocystitis, rhabdomyosarcoma, and trauma.

Emergency Department Treatment and Disposition

Obtain a complete history, including sinus disease, trauma, recent dental work, or infections. Perform an eye examination, palpating the periorbital area, checking visual acuity, assessing pupils and extraocular movements, and looking for injection and chemosis. Preseptal cellulitis is diagnosed by absence of all of the following findings: decreased visual acuity, pain with eye movement, chemosis or significant conjunctival injection, abnormal pupillary response or afferent papillary defect, proptosis, or diplopia. Any of the aforementioned findings indicate orbital cellulitis.

Order CBC with differential, blood culture, and wound culture as clinically indicated. Consider CT scan of orbits with thin slices (1- to 2-mm cuts) to evaluate for sinus disease, subperiosteal abscess, and consult ophthalmology. Admit children with moderate to severe preseptal cellulitis or patients 1 year for IV antibiotics (eg, ampicillin/sulbactam, ceftriaxone, or vancomycin, if methicillin-resistant S aureus [MRSA] is a possibility]). For patients with mild preseptal cellulitis (not clinically ill), give oral antibiotics (eg, amoxicillin clavulanate [Augmentin] or cefaclor) for 10 days with very close follow-up.

If conjunctivitis is present, recommend warm compresses 3 times a day, bacitracin ophthalmic ointment, or polymyxin-trimethoprim (Polytrim) drops. Incision and drainage may be necessary if an abscess does not improve with antibiotics.

Pearls

1. Vesicular rash suggests herpetic periorbital infection.

2. Close follow-up is mandatory as rarely preseptal cellulitis may progress to orbital cellulites and can be clinically indistinguishable from preseptal cellulitis.

Clinical Summary

Chalazion is a result of obstruction and inflammation of the meibomian glands (oil-secreting glands that produce sebum [oil] component of tear film), which are located in the tarsal plate of the eyelids. When these glands become inflamed and obstructed (eg, blepharitis), sebum leaks into surrounding tissue, forming a chalazion filled with lipogranulomatous material. Hordeolum results from acute infection of the sebaceous (stye or external hordeolum) or meibomian glands (internal hordeolum).

Patients present with a visible and palpable circumscribed nodule in the eyelid that is usually solitary but may be bilateral or multiple. Localized edema, erythema, and tenderness may be present, especially when there is a hordeolum. There may be visible “pointing” of mucopurulent discharge or drainage/crusting of skin. Patients may complain of chronic itchy eyes associated with blepharitis or have prior history of chalazion or hordeolum. Differential diagnosis includes preseptal cellulitis or pyogenic granuloma.

Emergency Department Treatment and Disposition

Perform an ocular exam including visual acuity and external exam of eyelids and eye, looking for visible signs of discharge or drainage. Edema is usually localized to the lesion. The conjunctiva and sclera are usually uninvolved. Palpation for preauricular lymphadenopathy helps to distinguish viral conjunctivitis (positive node) from other types of conjunctivitis.

Consult ophthalmology if there is significant injection or globe pain. Discharge patients with instructions to start aggressive warm compresses for 15 to 20 minutes, 4 to 6 times a day with light massage of lesion. If discharge or drainage is present, give topical antibiotic ointment such as bacitracin or erythromycin ophthalmic ointment.

Pearls

1. If there is associated edema and erythema, or systemic symptoms such as fever or chills, give systemic antibiotics with staphylococcal and streptococcal coverage.

2. Refer patients with chalazion lasting more than 3 weeks for outpatient follow-up with an ophthalmologist.

3. A hordeolum may cause a preseptal cellulitis or deeper abscess consult ophthalmology when edema, erythema, and pain worsen or if it becomes less localized.

Clinical Summary

Acute conjunctivitis may be infectious or noninfectious and by definition has a duration of less than 4 weeks. Adenoviral infections are the most common cause of viral conjunctivitis (“pink eye”). Patients present with conjunctival hyperemia, lid edema, serous discharge, foreign body (FB) sensation, and preauricular lymphadenopathy, and often complain of eyelids sticking together (worse in the morning). Acute conjunctivitis may initially present with unilateral symptoms; however, both eyes usually become affected. Consider herpes simplex infection with unilateral conjunctivitis with a vesicular skin rash or crusted lesions on eyelid margin.

Bacterial and viral conjunctivitis can be difficult to distinguish from one another and numerous bacterial pathogens cause conjunctivitis, including S aureus, S pneumoniae, Haemophilus species, or M catarrhalis. A “positive node,” or lymphadenopathy found on preauricular palpation, may help distinguish viral conjunctivitis from other types.

Patients may present with scant discharge or crusting, mild lid edema and injection, or in severe presentations, moderate to severe mucopurulent discharge with significant injection and lid edema. Copious and hyperacute mucopurulent discharge may represent gonococcal conjunctivitis.

Allergic conjunctivitis may present similarly to infectious conjunctivitis but tends to be bilateral and presents with watery discharge, eyelid edema, pruritus, and boggy chemosis.

Differential diagnosis of conjunctivitis includes viral (including herpes simplex [HSV]), bacterial, or allergic conjunctivitis; atopic/vernal conjunctivitis; uveitis; and periorbital cellulitis.

Emergency Department Treatment and Disposition

For viral or allergic conjunctivitis, provide instructions for supportive therapy, including cold compresses and preservative free artificial tears for symptomatic relief. Counsel patients that viral conjunctivitis is self-limited; however, it may get worse for the first 4 to 7 days after onset but generally resolves in 2 to 3 weeks (longer if there is corneal involvement). Inquire about anyone in the household with “pink eye” or a recent upper respiratory tract infection. Educate patients on strict hand hygiene as transmission is through contact and patients are contagious for 12 to 14 days. Children with weeping discharge should stay home from school.

If bacterial conjunctivitis is suspected, send discharge for culture, and start topical antibiotic therapy (eg, trimethoprim/polymyxin B 4 times a day or erythromycin ointment thrice daily) for 5 to 7 days. Avoid fluoroquinolone drops in younger children as systemic side effects are possible. If gonococcal conjunctivitis is suspected, send conjunctival swabs for Gram stain and culture, provide systemic therapy (eg, ceftriaxone) and consult ophthalmology to exclude corneal involvement.

For moderate cases of allergic conjunctivitis, consider prescribing olopatadine 0.1% (Patanol) twice a day, or ketotifen 0.025% twice a day. In severe cases, a topical steroid eye drop may be beneficial; however, this should only be prescribed by an ophthalmologist who can monitor for possible side effects.

Pearls

1. Check the “ocular vital signs” (red reflex, pupil, visual acuity, and motility) in any child with conjunctivitis.

2. Ocular pain is usually not associated with allergic, viral, and bacterial conjunctivitis and mandates consultation with ophthalmology.

3. Globe tenderness, diminished vision, and severe photophobia are all signs of more serious infection and also mandate consultation with ophthalmology.

4. Photophobia, pseudomembranes or membranes, chemosis, or subconjunctival hemorrhage may indicate epidemic keratoconjunctivitis (EKC), an adenoviral conjunctivitis (sero types 8 and 19) that may involve the cornea. If EKC is suspected, give follow-up with an ophthalmologist.

5. If HSV infection suspected, consult ophthalmology to exclude corneal involvement (risk of corneal involvement high with lesions on eyelid margin).

6. Consider sexual abuse (in appropriate setting) if gonococcal conjunctivitis is confirmed by culture.

Clinical Summary

Ophthalmia neonatorum is inflammation or infection of the conjunctiva within the first month of life. Neonates may present with diffuse conjunctival injection, purulent or mucopurulent discharge, eyelid edema, and possibly chemosis. The etiology may be infectious or chemical (eg, silver nitrate prophylaxis at birth). The time frame of presentation of symptoms is helpful in determining the etiology, and managing this condition as chemical conjunctivitis is seen within hours of sliver nitrate instillation and usually lasts 24 to 36 hours. Chemical conjunctivitis has become rare as erythromycin ointment has replaced silver nitrate as the prophylactic ointment. On Gram stain, no organism is seen, only a few white blood cells (WBCs). In contrast, Neisseria gonorrhoeae is usually seen 3 to 4 days after birth and has a variable presentation. Newborns may present with mild conjunctival hyperemia whereas others present with hyperacute, copious discharge, severe chemosis, corneal ulceration, or even perforation. Gram stain reveals gram-negative intracellular diplococci. Chlamydia trachomatis usually presents 1 to 2 weeks after birth with mild swelling, injection, tearing, and mucoid discharge. Giemsa stain is the best stain to visualize intracellular inclusion bodies in conjunctival epithelial cells or neutrophils. Nongonococcal bacterial pathogens including staphylococci, streptococci, or other gram-negative species may be seen on Gram stain during the neonatal period. Differential diagnosis includes dacryocystitis, nasolacrimal duct obstruction, and congenital glaucoma.

Emergency Department Treatment and Disposition

Perform an ocular exam with penlight in the ED with fluorescein staining to evaluate for corneal involvement. Chemical conjunctivitis does not need treatment as it is typically self-limited. Reevaluate the baby 24 hours after presentation to confirm conjunctivitis is resolving. For neonates with suspected infectious etiology, consult ophthalmology to further evaluate and obtain conjunctival scrapings for Gram stain and cultures. Culture of the inferior palpebral conjunctiva will increase the yield of cultures. Send conjunctival scrapings for chlamydial PCR testing or immunofluorescent antibody testing, as well as a sterile moist cotton tip applicator for viral cultures. If gram-negative intracellular diplococci are found on gram stain, admit the patient and observe contact precautions until systemic antibiotics have been given for 24 hours. Perform a complete systemic workup, including blood and CSF cultures. Treat initially based on Gram and Giemsa stain and modify antibacterial treatment as culture results are confirmed. Provide systemic treatment for both chlamydial and gonococcal conjunctivitis.

Pearls

1. Consider herpes simplex infections ophthalmia neonatorum, which may require both systemic and topical therapy.

2. Treat mother and notify her sexual partner for treatment with systemic antibiotics if cultures show an STD.

3. Suspect chlamydial infection if symptoms persist or worsen despite treatment for gonococcal conjunctivitis; chlamydial conjunctivitis may be accompanied by other systemic manifestations such as pneumonia.

Clinical Summary

Leukocoria can be caused by a number of disease processes including local causes such as cataract or a potentially malignant process. Hypopyon with leukocoria in a 1- to 2-year-old is highly suspicious for malignant retinoblastoma. Leukocoria at birth is suggestive of congenital cataract, which may be either unilateral or bilateral, or persistent hyperplastic primary vitreous (PHPV). PHPV is also frequently associated with a congenital cataract. Differential diagnosis includes cataract, retinoblastoma, Coat disease, PHPV, toxocariasis, retinopathy of prematurity (ROP), and astrocytic hamartoma. Patient presents with a white pupil and decreased vision if testing is possible. An absent red reflex leads to diagnosis of leukocoria in many instances.

Emergency Department Treatment and Disposition

Once the diagnosis of leukocoria is made, refer the patient to ophthalmology promptly. Regardless of etiology, a full ophthalmologic exam with imaging is necessary to render a proper diagnosis and exclude life-threatening etiologies. Do not treat specifically in the ED as the cause of the problem must first be ascertained.

Pearls

1. Absent red reflex and decreased visual acuity are findings of leucoria.

2. Check child for systemic abnormalities. Leukocoria is a marker of underlying pathology.

3. The most common presenting signs of retinoblastoma are leukocoria and strabismus.

Clinical Summary

Congenital glaucoma is present at birth and usually diagnosed shortly thereafter; most cases are diagnosed during the first year of life. Sometimes, however, it is not recognized until later in infancy or into early childhood. The characteristic signs include the triad of blepharospasm, tearing, and photosensitivity. The affected eye of the infant may appear much more enlarged (buphthalmos) than the normal eye with megalocornea, and the cornea may appear cloudy.

Infantile glaucoma presents later in life (up to age 3) and occurs secondary to a gradual increase of the intraocular pressure (IOP). These patients do not present with the typical triad of congenital glaucoma but with impaired vision and a possible strabismus (crossed eyes). Differential diagnosis includes congenital megalocornea, trauma during delivery with corneal injury, congenital hereditary corneal dystrophy, and congenital infections (eg, congenital rubella, herpes simplex virus).

Emergency Department Treatment and Disposition

Treat patients with increased IOP with topical aqueous suppressants such as beta-blockers (ie, timolol), carbonic anhydrase inhibitors (ie, acetazolamide), and prostaglandins (eg, latanoprost). Do not use α-adrenergic aqueous suppressants (ie, brimonidine) in children as they may cause central nervous system suppression. Surgery will be required as definitive treatment. Consult ophthalmology emergently to rule out and distinguish other causes of excessive tearing and photosensitivity such as a FB, conjunctivitis, and nasolacrimal duct obstruction.

Pearls

1. Infantile glaucoma is a vision-threatening disorder marked by increased IOP that presents before the age of 3.

2. Corneal breaks (Haab striae) may be evident on a penlight exam.

3. Tearing is the most common sign.

4. The classic triad is only seen in a third of the affected patients at the time of diagnosis.

5. Megalocornea (corneal diameter of >10 mm in a term infant or >12 mm in an infant at 1 year of age) strongly suggests glaucoma.

Clinical Summary

Patient presents with an FB sensation and usually some irritation of eye. There is frequently excessive tearing and possibly photophobia (light sensitivity) with redness of the eye. Vision may or may not be affected based on the location of the FB and the amount of inflammation in the surrounding corneal tissue. Historically, many patients recall the nature and time of the FB occurrence. Rarely, however, a small FB can cause the aforementioned symptoms without any specific recollection of an event leading up to it. The eye is minimally to moderately inflamed on presentation. Differential diagnosis includes corneal infection; however, diagnosis is usually straightforward.

Emergency Department Treatment and Disposition

Take history and assess vision of the patient. Bright direct illumination can often make the diagnosis without a slit lamp microscope if it is not available. Use fluorescein staining to aid diagnosis. If someone other than an ophthalmologist is attempting removal of the FB, make sure to assess its depth at the slit lamp prior to removal.

A very superficial FB can sometimes be removed by irrigation or a cotton tip applicator if it lies superficially on the corneal epithelium. Instill 2 drops of local anesthesia (eg, proparacaine), moisten the end of cotton tip applicator, and softly brush the area where the FB lies. Do not rub firmly as this can further embed the FB into the corneal stroma. Prescribe topical antibiotics for 5 days after removal.

For deeper FBs, consult ophthalmology for removal with a bent needle using the slit lamp. If prompt ophthalmologic consultation is not available, start topical antibiotics and refer for evaluation the next day.

Pearls

1. Pain frequently is referred to the upper eyelid and visual acuity is variably affected.

2. Fluorescein staining of the cornea can reveal the location of the FB.

Clinical Summary

Corneal abrasions occur when the corneal epithelium is removed. Patients usually present with sharp pain, photophobia, FB sensation (even in absence of an FB), tearing, and worsening pain with blinking and blurred vision (abrasion centrally located in visual axis). Patients can often recall a history of trauma such as being hit in the eye with a hand, fist, fingernail, piece of paper, or a history of something flying into their eye with subsequent rubbing of their eye. Inquire about contact lens wear, history of prior corneal abrasion, or skin lesions or rashes. Differential diagnosis includes herpetic keratitis, corneal ulcer, dry eyes, corneal FB, contact lens overwear, and recurrent corneal erosion.

Emergency Department Treatment and Disposition

Confirm diagnosis with fluorescein stain of the cornea. Place a drop of topical anesthetic (ie, tetracaine or proparacaine) into eye and then gently touch fluorescein strip to conjunctiva (not cornea). Evaluate visual acuity and the anterior portion of the eye and lids for any other injury such as FB or laceration of cornea or conjunctiva. Consult ophthalmology for patients with large corneal abrasions with centrally located epithelial defects in the visual axis or history of contact lens use. Refer patients for next day evaluation if ophthalmologist is unavailable. Patching an uncomplicated abrasion with a pressure patch or alternatively using a contact lens usually resolves the problem in 24 to 36 hours. Discharge the patient with topical antibiotic ointment at bedtime or drops 4 times a day (eg, erythromycin or bacitracin ophthalmic ointment or polymyxin B/trimethoprim) to be used after the patch is removed with close follow-up.

Pearls

1. Pain and FB sensation are the cardinal symptoms of corneal abrasion.

2. Infants with corneal abrasions present with excessive crying.

3. Never dispense topical anesthetic for continued use.

4. Select antibiotic drops or ointment with pseudomonal coverage (eg, gatifloxacin, moxifloxacin, or tobramycin) in contact lens wearer and recommend a contact lens holiday for at least 10 to 14 days.

5. Corneal abrasion is a relatively minor eye injury that can lead to more serious consequences, if mistreated.

6. If epithelial defect is associated with visible corneal opacities such as a whitish lesion near fluorescein uptake, suspect corneal ulcer and consult ophthalmology emergently.

Clinical Summary

Patients present with a painful inflamed eye and sometimes with discharge, and complaints of blurry vision and FB sensation. Typically, vision is decreased on visual acuity testing, and this may be severe in badly infected eyes. Many patients will give a history of ocular trauma or contact lens use. Corneal FBs can also cause these symptoms. Photophobia is generally present and fluorescein testing often reveals an epithelial defect. A corneal opacity can sometimes be seen on direct illumination prior to the instillation of fluorescein dye. Differential diagnosis includes corneal herpetic infection, bacterial infection, and fungal or parasitic keratitis.

Emergency Department Treatment and Disposition

Assess history and evaluate visual acuity. Use bright direct illumination to identify corneal opacities, which can aid diagnosis. Use fluorescein staining to confirm the presence of ulceration. For small ulcers with minimal symptoms and mild decrease in vision, start topical antibiotics and refer the patient for ophthalmologic exam in 24 hours. For contact lens–associated ulcers, use a fourth-generation fluoroquinolone plus polymyxin/trimethoprim combination. Consult ophthalmology emergently in cases with either severely diminished vision or with a perforation or with an associated hypopyon.

Pearls

1. Suspect herpes simplex keratitis if corneal ulceration is present with no history of ocular trauma or contact lens use. Dendritic ulceration also suggests herpes simplex as an etiology.

2. For contact lens users with possible corneal ulceration, instruct patients to immediately discontinue use of their lenses.

Clinical Summary

Hypopyon is the accumulation of whitish or grayish material layered in the anterior chamber of the eye and is a sign of an infectious or inflammatory process such as endophthalmitis, uveitis, a corneal ulcer, and rarely retinoblastoma. Patients may present with no history that indicates etiology (spontaneous) or after some significant trauma to the eye. The patient usually has an associated loss of vision, pain, and photosensitivity. Differential diagnosis includes corneal ulcer, endophthalmitis, postintraocular surgery, posttraumatic, retained intraocular FB, masquerade syndrome such as retinoblastoma in young child, juvenile xanthogranuloma, and bleeding diathesis.

Emergency Department Treatment and Disposition

Take a history that includes contact lens use, ocular surgery, and family history of ocular problems. Consult ophthalmology emergently. Prescribe antibiotic or anti-inflammatory topical medications depending on the ocular and systemic findings and underlying etiology leading to hypopyon.

Pearls

1. A hypopyon is a medical emergency because it may signal endophthalmitis.

2. The hypopyon is composed of a collection of leukocytes.

Clinical Summary

Hyphema is the accumulation of blood in the anterior chamber of the eye and typically occurs as a result of ocular trauma, but may occur spontaneously in infants with juvenile xanthogranuloma of the iris or retinoblastoma. Patients present with a red, painful eye and a decrease in visual acuity. IOP is frequently elevated and must be monitored. There is a risk of a spontaneous rebleed within 5 days in cases of trauma, which may lead to further complications such as glaucoma and corneal blood staining. The amount of the blood in the anterior chamber can vary from totally filling the anterior chamber to a microscopic amount leading to an abnormal red reflex. Patients with sickle cell trait or disease are at greater risk of severe ocular complications and may be candidates for earlier surgical intervention. Differential diagnosis includes iris neovascularization, trauma, blood disorder, HSV or herpes zoster virus infection, iridocyclitis, postsurgical, and intraocular tumor.

Emergency Department Treatment and Disposition

Take a history with attention to sickle cell disease and test for sickle cell if history is unknown or unreliable. Consult ophthalmology and admit the patient for bedrest and head elevation to facilitate layering of the hyphema. Place an eye shield (not eye patch) over the injured eye. Do not give aspirin-containing medications for pain. Provide topical or systemic medications for treatment of ocular complications if they are evident.

Pearls

1. Consult ophthalmology emergently to exclude ruptured globe and to obtain IOP.

2. Aspirin-like products are contraindicated because of the risk of a rebleed.

3. Size of the hyphema is not often related to risk of rebleed or ocular sequelae.

4. The presence of hyphema in the absence of trauma should prompt an investigation for underlying disease (eg, leukemia or coagulopathy).

Clinical Summary

Subconjunctival hemorrhage (SH) occurs when episcleral and conjunctival blood vessels burst, which may result from eye trauma, hypertension, bleeding disorders/coagulopathy, and anticoagulant medications. Traumatic subconjunctival hemorrhage may be associated with periorbital fracture or zygomatic fractures. Atraumatic SH presents with a red patch (sectoral or diffuse) on the white part of the eye and no associated pain or loss of vision and may be caused by sneezing, Valsalva maneuver, or adenoviral infection. There is no mucous discharge, no excessive or abnormal tearing, and no pain with eye movements or with palpation over the red area. Recurrent hemorrhages or bleeding from other sites require workup for thrombocytopenia or other bleeding disorder. Differential diagnosis includes episcleritis, conjunctivitis, and Kaposi sarcoma in an immunocompromised patient.

Emergency Department Treatment and Disposition

No treatment is needed for isolated subconjunctival hemorrhage. Reassure patient that it is benign and will resolve within 1 to 2 weeks. No workup is needed unless there are repeated episodes, signs of systemic bleeding disorders (easy bruising and bleeding), and the patient is not on any blood thinner. If there is a history of trauma, exclude associated conditions such as corneal abrasion and globe injury.

Pearls

1. Exclude severe injury to the globe if there is severe eye pain, photophobia, decreased visual acuity, or extension of the hemorrhage beyond the limbus.

2. In blunt trauma to the eye, a 360° SH may obscure an underlying ruptured globe.

Clinical Summary

Eyelid lacerations are classified as having no lid margin involvement, having lid margin involvement, and medial canthal lacerations, with involvement of the canalicular system or tear-drainage system (any laceration medial to punctum is at high risk of canalicular involvement). Patients usually present with history of trauma and may have associated ocular injuries, such as scleral, conjunctival, or corneal lacerations as well as intraocular FB and penetration of the globe.

Emergency Department Treatment and Disposition

Take a careful history to determine the mechanism of injury, and perform a complete ocular examination and assess need for diagnostic tests and treatments. If there is an FB, ruptured globe, or severe trauma is suspected, obtain head CT (with 1-mm cuts). Consider tetanus prophylaxis when indicated and administer systemic antibiotics for contaminated wounds or suspected FB. If human or animal bites induced the injury, consider penicillin V and rabies prophylaxis as indicated. Consult ophthalmology in the ED, if available, to assess and repair the eyelid laceration. Discharge patient with ophthalmic antibiotic ointment to apply to the repaired laceration with close follow-up.

Pearls

1. Check “ocular vital signs” (red reflex, pupil, visual acuity, and motility) in any child presenting with ocular trauma.

2. Ensure that lacerations involving the margin are reapproximated well and tarsus realigned to reduce risk of ectropion, entropion, notching, or lagophthalmos.

3. All lacerations medial to the puncta require probing and irrigation to determine canalicular involvement.

4. The presence of orbital fat represents a deeper laceration in which the orbital septum has been violated. This often requires exploration of the deeper tissue of the eyelid in the operating room.

Clinical Summary

Patients present with decreased vision and pain in a very inflamed eye. History is generally ascertainable and important in decision making. Many cases are due to blunt trauma (eg, motor vehicle accidents, assault), a fall into a sharp object, or a cut by a penetrating FB. The eye may have 360° of subconjunctival hemorrhage, iris prolapse, hyphema of the anterior chamber, and a diminished or absent light reflex. Pupillary reaction may be abnormal based on extent of injury. The eye may appear distorted on clinical exam; presence of uveal tissue on the ocular surface is a sign that rupture has occurred. The lens may be outside the normal location either in the anterior or posterior chamber or even outside the eye. Low IOP is present in most cases. Most traumatic globe ruptures are at the limbal area or at the insertion of the intraocular muscles into the globe, and the eye may have limited extraocular movements on motility testing. Differential diagnosis includes severely contused eye without rupture, severely infected eye, buphthalmic eye with possible ruptured cornea, keratoconus eye with corneal hydrops.

Emergency Department Treatment and Disposition

Evaluate the globe carefully and perform vision assessment and inspect the pupil carefully. Obtain neuroimaging as it aids in the diagnosis in subtle cases, helps to assess the status of the periocular tissues/structures, and detects intraocular FBs. Do NOT use ocular ultrasound if globe rupture is suspected as undue pressure may help extrude intraocular contents. Place a protective shield over the eye once the diagnosis is made or considered. Consult ophthalmology emergently and give broad-spectrum IV antibiotics (eg, ceftazidime and vancomycin) that provide coverage against gram-positive and gram-negative organisms, including Bacillus species (contamination with organic FB). Globe rupture requires urgent operative repair; keep patient NPO (nothing by mouth). Consider tetanus toxoid as indicated and provide antiemetics, analgesics, and sedation, which may minimize expulsion of intraocular contents.

Pearls

1. Traumatic globe rupture represents a true ophthalmic emergency.

2. An abnormally peaked pupil can be a clue to the diagnosis in less-inflamed eyes.

3. Following blunt trauma to the eye, a 360° subconjunctival hemorrhage may obscure an underlying ruptured globe.

4. If globe rupture is diagnosed, do not manipulate/examine the eye further. Instead, place a protective shield over the eye without a patch.

5. Instruct patient to avoid Valsalva maneuvers before surgical repair to avoid extrusion of intraocular contents.

Clinical Summary

Chemical burns of the eye from acidic or basic material are an ophthalmologic emergency. Patients present with red and inflamed eyes that tend to be very painful. Swelling of the conjunctiva can be seen and a corneal epithelial defect will be noted on fluorescein staining. The extent of the corneal defect has prognostic significance. In severe injuries, certain parts of the limbus may appear ischemic giving the false impression that the eye is not inflamed. This limbal ischemia can be associated with corneal clouding in the areas served by that limbal region. Furthermore, although acids tend to be precipitated by corneal tissue, which can somewhat limit damage/penetration into the eye, basic substances can degrade corneal tissue and cause very severe irreversible damage to intraocular structures. In severe chemical injury, the cornea can be opacified on presentation and is not a good prognostic sign.

Emergency Department Treatment and Disposition

Diagnosis is straightforward given a history of chemical accident. Consult ophthalmology promptly. Assess vision and corneal loss with fluorescein staining first and then start immediate irrigation with saline or Ringer’s lactate solution. Place topical anesthesia into the eye prior to irrigation with IV tubing. Use a Morgan lens to deliver the irrigating solution. Sweep eyelid fornices gently with either a moistened cotton tip applicator or a glass rod to remove any remaining caustic material. Check pH 10 minutes after irrigation is stopped to reassess the pH of ocular surface and continue irrigation until pH of 7.0 is achieved. This may require many liters of fluid. In very severe cases, fluid may be irrigated onto the ocular surface for 24 to 48 hours. The use of amniotic membranes in the acute setting by the ophthalmologist can be considered in the treatment regimen. Initiate topical antibiotics (not in ointment form) in the ED to prevent infection.

Pearls

1. Irrigation and restoration of the normal pH is the key to successful management.

2. Basic chemical burns tend to be worse than acidic burns and urgently require more irrigation.