38 year old female presents to the Emergency Department with reports of left eye pain, discomfort and haziness to her vision. Like the excellent physician that you are, you take a look at her eye. 

Is the eye red with a weird line on the front? Or does the patient have injected conjunctiva, a ciliary flush and a hypopyon? There are several aspects to the eye that create a high yield, tough to study field of medicine. Not to worry, let’s start with the basics: 

Eye evaluations 

Every patient with an eye complaint should have a full evaluation including vision acuity, bilateral intraocular pressures, extraocular motion, with potential use of slit lamp and fluorescein uptake dye and woods lamp. Several aspects of emergency medicine will also incorporate early consultation of ophthalmology to ensure prevention of patient’s permanent vision impairment/loss. 

Glaucoma 

Intraocular pressure goes hand in hand with glaucoma and should be kept in the differential with all patients presenting with eye pain. Incredibly high yield, this is often presented as a patient with eye pain in dark rooms, nausea, vomiting, headache with a fixed mid-dilated pupil and an elevated intraocular pressure (normal IOP is 10-20). 

The majority of questions pertain to treatment which includes opthalmology consultation, placing patient supine, timolol 0.5%, apraclonidine 1.0% and PO acetazolamide 500 mg ⁴

Conjunctivitis

Patients often diagnose themselves with pink eye without our help. However there are three types of conjunctivitis to be aware of presenting to the emergency department. One thing to keep in mind, is that all patients presenting with conjunctivitis should receive examination following fluorescein staining to rule out abrasions, ulcers and in the case of viral conjunctivitis, dendritic lesions. 

Bacterial conjunctivitis

Often associated with matting of the eyelashes, conjunctival injection/inflammation, purulent discharge. First line treatment is topical antibiotics for 5-7 days often in the form of erythromycin ointment. If patients continue to not improve this may be a case of haemophilus influenza and moraxella catarrhalis. Always keep in mind patients with contact lenses need coverage for pseudomonas such as ciprofloxacin.⁴ 

Viral Conjunctivitis 

Often also presenting with conjunctival inflammation, watery discharge or noted chemosis. This can be associated with recent viral infection and as discussed should have fluorescein staining to rule out dendritic lesions. As noted by Tintinallis, treatment is cold compresses four times daily, naphazoline 0.025% one drop three times daily and artificial tears with an ophthalmology follow up in 7-14 days

A high yield, clinically important infection to keep in mind is a herpes simplex virus (HSV) in relation to the eye. Classically seen as the dendritic lesion, this can be much more variable than noted in textbooks and can often be subtle⁴. Ophthalmology consultation should be obtained for prompt follow up along with:

Eyelid involvement alone  Acyclovir 800 mg five times daily for 7-10 days

Conjunctiva involvement  Trifluorothymidine 1% drops nine times daily

Erythromycin 0.5% ointment twice daily, warm soaks three times daily

Always, always, always, avoid steroids if this is suspected. 

Herpes zoster ophthalmicus is when the trigeminal distribution also becomes affected and should always be suspected with patients presenting with shingles involving the tip of their nose. Treatment should once again follow a similar pathway to HSV infection including acyclovir or potentially famciclovir/valacyclovir. Keep in mind, severe cases may require acyclovir IV².  

An important note from literature is that when unable to differentiate between viral or bacterial, to provide antibiotics. However routine prescribing of antibiotics is discouraged. 

Allergic conjunctivitis

Noted to have pruritis, watery discharge and chemosis with noted history of allergies¹. On slit lamp examination, patient may have noted conjunctival papillae. Similar to viral, treatment consists of old compresses four times daily, naphazoline 0.025% one drop three times daily and artificial tears with an ophthalmology follow up in 7-14 days

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UV Keratitis Punctate Lesions⁶

Corneal abrasion/UV keratitis

Often secondary to accidental trauma, corneal abrasions cause tearing, pain and photophobia. Prior to fluorescein stain examination, proparacaine 0.5% drops should be used. Proparacaine has been noted to have less initial pain with similar anesthesia to tetracaine. Examination of eye should always include eyelid eversion for foreign body. 

Treatment includes Ketorolac ophthalmic solution drops four times daily for pain control and erythromycin ointment with special care for patients that use contact lenses. With a higher propensity for pseudomonas infections treatment should include ciprofloxacin/ofloxacin with instructions to not place an eye patch as this may worsen infection. 

UV keratitis is injury from exposure to UV light including welding, snow covered slopes or sun exposure. This presents with punctate corneal abrasions on exam and should be treated similar to abrasions with special care for higher levels of pain control. 

Corneal ulcers

Infection of corneal stroma secondary to bacterial, viral or fungal infection often seen secondary to trauma or extended contact lens use. Patients present with photophobia, blurred vision, pain and injected conjunctiva with immunocompromised patients at increased risk for viral or fungal etiology. 

On slit lamp examination this will appear to be a defect with surrounding hazy infiltrate, iritis and in some cases a hypopyon. Treatment includes topical olofloxacin or ciprofloxacin 0.3% ophthalmic solution with one drop per hour and possibly cyclopentolate 1% three times daily for pain relief. As with most eye cases, avoid steroid drops until consulting with an ophthalmologist. If possible, an ophthalmologist may ask to culture the ulceration prior to antibiotics, but these patients should follow up with ophthalmology within 12-24 hours.

Iritis

Presenting with photophobia, red eye and decreased vision this is a condition in which patients have an inflammation of the iris/ciliary body (anterior uveal tract). WBCs may be noted on slit lamp exam, hypopyon and a full eye examination including intraocular pressure, fluoroscein dye. 

The key mark physical exam finding in iritis is consensual photophobia which is when light shined into the unaffected eye causes pain to affected eye

Endophthalmitis

This is an infection of structures within the globe with patients experiencing vision loss and pain likely following ocular trauma or surgery. Hematologic spread is possible and thus these patients should have full septic work up with emergency ophthalmology consultation. 

Subconjunctival hemorrhage

Often appearing much worse than they look, a subconjunctival hemorrhage is secondary to trauma, sneezing or valsalva in which conjunctival blood vessels are disrupted. 

Corneal foreign bodies

Patients should have analgesia in both affected and unaffected eye prior to removal as this decreases reflex blinking. From here, a 25 gauge needle or ophthalmic burr. A ring of rust left following the removal of metallic foreign body should be removed in 24-48 hours and should be treated similar to corneal abrasions (antibiotics, analgesia as needed). Keep in mind, all signs of gross or micro hyphema could potentially indicate globe rupture. 

Lid laceration

Although many types of eyelid laceration may be repaired in the emergency department, there are a few situations that warrant ophthalmology/plastics consultation⁴:

-Laceration involving lid margin >1 mm 

-Inner surface of lid

-Involving tarsal plate/levator palpebrae muscles

-Laceration causing ptosis

Lid margin lacerations under 1 mm can heal spontaneously, and patients presenting with lid lacerations should have a full evaluation regarding possible corneal abrasion or globe injury. Disposition will depend on ophthalmology consultation however low risk patients may receive 500 mg cephalexin four times daily with erythromycin 2% four times daily and followed up as outpatient in 24 hours.

Blunt eye trauma

Patients presenting with abnormal anterior chamber length, blindness or an irregular pupil should be considered a globe rupture until proven otherwise with eye shield placement and immediate ophthalmology consultation 

Hyphema

Blood in the anterior chamber is seen following trauma or in patients with coagulopathies such as sickle cell disease. This is also an emergent consultation to ophthalmology with the patient placed in 30 to 45 degrees or fully upright to prevent corneal staining and permanent alteration to vision. As these patients have a high likelihood of rebleeding in 3-5 days, ophthalmology must evaluate at bedside to dictate the necessity of surgical intervention. 

Orbital blow out

Fracture of the orbital wall (most commonly inferior/medial wall) may lead to entrapment of the inferior rectus muscle. This causes diplopia with upward gaze, infraorbital paresthesia and should be diagnosed with CT. As noted in Tintinalli’s, 33% of these patients have an ocular injury and thus a thorough eye examination should take place. 10 day course of cephalexin 500 mg four times daily is recommended as this may have sinus involvement as well. 

Regardless of whether entrapment has taken place, all patients should follow up with opthalmology to rule out retinal injury. 

Penetrating eye trauma

A high index of suspicion for penetrating eye trauma should always be had as this is not always an obvious presentation. Patients with tear shaped pupil, hyphema, extrusion of globe content, severe conjunctival hemorrhage, increased anterior chamber depth,reduction of vision should be suspected of penetrating injury. Important to note however that a patient may present with a mechanism suggestive of penetrating injury as well, including high speed projectiles, welding, grinding or cutting. 

Fluorescein placed in the eye will show a positive seidel sign as seen below. This is the extravasation of the aqueous humor and is pathognomonic for a penetrating eye injury. Absence of this however does not rule out a penetrating injury, nor does the presence of corneal ulcer or abrasion. Patients with suspected injury should be placed in an eye shield, kept upright, NPO and receive antibiotics with emergent consultation of ophthalmology. 

Chemical ocular burn

Whether acid or alkali, patients should receive topical anesthetic and use a morgan lens to irrigate eye with 2L of normal saline or lactated ringer. pH may be checked 30 minutes after irrigation is complete and in the event of a return to 7.4, eyes should be thoroughly inspected for foreign particles, visual acuity and patients placed on erythromycin 0.5% ointment.  

Super glue (cyanoacrylate) exposure

Initial removal of glue should be attempted with 0.5% erythromycin ointment application. Patients with eyelids that are unable to easily open should place ointment five times daily to soften glue, with follow-up in 24 hours with ophthalmologist. 

Optic neuritis

A board favorite, these patients present with acute vision loss and reduction of color vision. This is secondary to inflammation along the optic nerve, most commonly due to multiple sclerosis although it can also be of other etiology such as tuberculosis or syphilis. 

A red saturation test is when the patient looks at a dark red object with each eye separately. The affected eye will see a pink/light red object instead of dark. As with most other management, ophthalmology should be consulted with IV steroids/oral steroids given for visual recovery. 

Central retinal artery occlusion

Presenting with sudden, painless monocular vision these patients will notably also have an afferent pupillary defect and the hallmark sign of red macula with “cherry red spots.” Treatment/management is ophthalmology consult driven as past managements including direct massage or timolol have proven ineffective. 

Central retinal vein occlusion

Painful monocular vision loss described as blood and thunder on ocular exams should raise suspicion for venous occlusion. There is no treatment however medications including birth control and diuretics should be suspended until ophthalmology consultation can be obtained. 

Retinal detachment

Often presenting to the ED due to the acute nature of vision loss, these patients present with flashes of light, floaters or curtain-like defects. Bilateral detachment is rare outside of trauma and can be diagnosed at bedside by ultrasound. Ophthalmology consultation for possible surgical intervention is necessary. 

Temporal arteritis

This is a systemic vasculitis that may cause painless optic neuropathy. Generally seen in women over 50 with headache, vision changes and jaw claudication. Unlike previous, this may present in bilateral eyes with noted affarent pupillary defect. ESR/CRP should be ordered when suspected with majority of ESR seen at 70-100. Patients with suspected temporal arteritis or vision loss should be admitted for IV steroids with less likely/no vision loss discharged on prednisone with close follow up. 

Written by: Hakkam Zaghmout, MD

Peer Reviewed and Edited by: Stevely Koshy, DO

References

1. https://optometrist.com.au/
2. Aao.org
3. JETem.org
4. Tintinalli’s
5. CoreEM.net
6. Kwon DH, Moon JD, Park WJ, et al. Case series of keratitis in poultry abattoir workers induced by exposure to the ultraviolet disinfection lamp. Ann Occup Environ Med. 2016;28:3. Published 2016 Jan 15.
7. Teachmeanatomy.info

Authors Note:

Patient consent has been obtained for educational purposes.