Patients living in remote areas or those with limited access to the hospital care system typically present first to the primary health care physician if they sustain a traumatic injury to the eye. Therefore, it is essential for the general practitioner to have a general idea about the several types of acute ocular emergencies and to be able to manage them properly at the primary care level. The primary health care physician needs to make two important decisions in case of an ocular emergency: should the patient be referred to the emergency department at the hospital? And if yes, how and when should the referral be made?
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Eye orbit anatomy – anterior view

Image: “Eye orbit anatomy – anterior view” by Patrick J. Lynch, medical illustrator, License: CC BY 2.5


Background

Many patients presenting to the primary care facility with an ocular emergency are looking for reassurance and/or some information about the prognosis of their injury. Without proper knowledge in the field, the treating general practitioner might end up providing inaccurate information to the patient that can be misleading.

Before we discuss some of the common ocular emergencies that can be encountered at the primary care setting, we need to establish few important rules related to the care of acutely injured patients. A complete history is essential as it can give clues about the mechanism of injury, any legal actions needed, and the extent and nature of ocular trauma. The patient should be observed and examined with a bright light and a pen torch. At the primary care level, one should be able to identify foreign bodies, chemosis, corneal haze, and the presence of blood or pus in the anterior chamber of the eye. The presence and extend of corneal injuries should be also noted. The pupils should be also examined in the primary care facility looking for any pupillary defects or a dilated pupil.

Visual acuity should be assessed as soon as possible as it is the most important test in terms of prognosis and long-term outcomes. Additionally, any changes in visual acuity should warrant the primary health care physician that the patient need to be referred to the emergency department for an ophthalmologist consultation immediately.

Traumatic Ocular Injuries

Traumatic injuries to the eyes can be penetrating or nonpenetrating. The clinical characteristics and features of these two types of ocular injuries are a little bit different. Additionally, the clinical outcome and necessity for urgent referral to a hospital are somewhat dependent on the type of injury. The severity of the traumatic injury, however, is the most crucial factor in determining the course of action a primary care physician should follow when he or she encounters a patient with an ocular injury.

Penetrating Ocular Injuries

Fortunately, penetrating ocular injuries are rare. The presentation of a penetrating wound to the eye globe is usually dramatic. The pupil is usually irregular and nonreactive to light. Bubbles might be seen in the anterior chamber. Hyphaema is another common finding in penetrating ocular injuries.

When a patient presents with a penetrating ocular injury, the eye should neither be touched nor manipulated. Instead, it should be shielded and the patient should be referred to an emergency department at a nearby hospital for optimum ophthalmologic management. Before shielding the eye, one can apply a topical anesthetic and a topical antibiotic. The patient should also receive a tetanus booster dose if needed.

Nonpenetrating Ocular Injuries

Blunt trauma to the eye is more common compared to penetrating injuries. Blunt trauma might be caused by a direct hit with a ball or a fist, or an accidental fall. Lid edema is common, which can make the examination of the eye globe difficult. The pupil is usually dilated. Fractures of the orbit are common with blunt trauma to the face and eye. Therefore, the patient should be referred to a hospital at some point to get a computerized tomography scan of the orbital bones and exclude orbital fractures. The urgency of the referral of the patient is dependent on the severity of the injury. Hyphaema is also seen with nonpenetrating ocular injuries.

Severity of Ocular Trauma

As it has been mentioned already, the severity of ocular trauma is the most crucial factor in deciding when and how to refer the patient to a hospital. The severity of ocular trauma from a primary care point of view can be classified as mild, moderate or severe.

Mild ocular trauma is characterized by a visual acuity that is better than 6/12, absence of hyphaema, and a normal reactive pupil. A patient with a mild ocular trauma should undergo a dilated fundus examination and then referred to a tertiary health care center within 48 hours.

Moderate ocular trauma is characterized by a visual acuity between 6/12 and 6/24. Micro-hyphaema is present and the pupil is usually dilated. Such patients should undergo a dilated fundus examination followed by shielding of the eye. The patient should be referred to a tertiary health care center within 24 hours.

Patients with severe ocular trauma, defined as a visual acuity worse than 6/24, macro-hyphaema, and the presence of a pupil defect, should get their affected eye shielded. Immediate referral to a hospital emergency department should be attempted.

Chemical Ocular Injuries

Exposure of the eyes to corrosive chemicals is another common mechanism of ocular injury. The immediate irrigation of the eye with copious amounts of water is essential as it is known to prevent further damage of the eye.

Patients with chemical ocular injuries are often in exquisite pain. Therefore, topical anesthetic drops should be administered. This can be performed before starting the irrigation step as it can make the procedure less painful to the patient.

Sometimes, chemicals and foreign materials tend to stick under the lids. Therefore, a careful examination of the eye-lids should be attempted and any chemicals or materials should be removed. The next step in the management of these patients is to perform a baseline visual acuity test. Finally, all patients with chemical ocular injuries should be referred to the hospital emergency department as soon as possible.

Acute Angle Closure Glaucoma

Patients with acute angle closure glaucoma present with severe nausea, vomiting, eye-globe pain, headache and blurred vision. Acute angle closure glaucoma is more common in women, older than 50 years of age, who have family history of the disease.

The pupil is mid-dilated and the cornea is usually edematous. The patient typically has a rapid decrease in their visual acuity. Intra-ocular pressure testing is used to confirm the diagnosis. Once the diagnosis is confirmed, the patient should be referred for a tertiary health care center to an ophthalmologist.

Orbital Cellulitis

This is a life-threatening condition that can affect both eyes. Fortunately, the condition is rare. Patients are usually young adults. Fever and malaise are common. The affected eye will be proptosed and ocular movements will be painful. Visual acuity might be affected.

Many patients report a recent history of a paranasal sinus infection. It has been suggested that orbital cellulitis might happen as a consequence to direct extension of a paranasal infection “sinusitis” into the orbit. Preseptal cellulitis is a different condition that is characterized by the presence of eye-lid swelling, however eye movements are not restricted. Additionally, visual acuity is usually not affected in preseptal cellulitis.

Patients with orbital cellulitis should be referred to a hospital for inpatient treatment and hospitalization. Untreated orbital cellulitis can lead to brain abscess, cavernous sinus thrombosis and meningitis.

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