Now, primary care physicians don't see a ton
of ocular emergencies as part of continuity practice,
but if you ever work in
an urgent care setting,
you will see a lot of acute eye symptoms,
and therefore, it's really important to get to know
some of the diagnoses I’m about to
share with you in ocular emergencies.
Even if you don't see a
lot of these emergencies,
there are some principles here that are really
important and I think are worth sharing as well.
Let’s get underway.
And we’ll do a case.
So, I’ve got a 75-year-old male.
He had bilateral cataract surgery last year,
most common surgery in the United States.
But, today, he had a problem.
Sudden onset of floaters
and flashing lights in his left eye.
And so, he tried to do
an exam of that eye.
And it’s difficult.
You can't really get a good look
inside because of a constricted pupil.
So, just based on that
limited information alone,
what is the best course of
management for this patient right now?
Do, we, A, treat with a topical antibiotic?
B, treatment with systemic antibiotics?
C, immediate referral to ophthalmology?
Or D, referral for neuroimaging?
What do you think?
The answer is C.
And I’m going to make the
answer clear why in a second.
But this is a case of
probable retinal detachment
that needs emergent
evaluation by an ophthalmologist.
So, let's talk about a
retinal detachment first.
Then we’ll be moving on to globe
injuries and chemical injuries to the eye.
So, this gentleman has
all the risk factors for a
retinal detachment except the fact
that he didn’t have a previous detachment,
but he is older and has a
history of cataract surgery.
He has the right symptomatology.
Floaters plus flashing lights.
The visual defect can be variable.
Some patients actually can see
fairly well after a retinal detachment
and some people have a
much more blurry field.
this needs to be evaluated
once a detachment occurs,
their risk for ischemia goes up
and may not be regained.
The good news with
retinal detachment is,
when the macula is involved,
most patients who receive surgery
do achieve a satisfactory result in terms
of getting 20/40 vision or better.
And these patients should
also be followed because,
as I mentioned,
previous detachment is a major risk
factor for subsequent detachment.
So, up to a quarter will actually experience
detachment on the opposite eye at some point.
And those are the points I just made.
Let’s talk about mechanical globe injury.
So, this can be a full thickness tear,
either through the cornea
or through the sclera.
It’s often related to high velocity,
high-impact injuries like
with this rocket ship.
You don't want that
hitting you in the eye.
Symptoms, as you can
imagine, pain, but also redness,
tearing and decreased vision.
And we’ll talk about how redness is one
thing, but ocular pain is a different thing.
And when I talk about ocular pain,
I’m talking about a pain in the globe.
Patients with conjunctivitis feel
irritation, burning, itching,
but it's not necessarily
a deep boring kind of pain.
A mechanical globe injury, that's going
to be actual pain in the globe
and always should be a red flag
for an emergent condition.
Now, the good news with a
mechanical globe injury,
if it's fairly straightforward and
you can diagnose it as
just a conjunctival laceration
and it’s less than a centimeter,
they don’t need to be referred,
they can receive topical
antibiotics and follow-up
and should be okay.
Anytime you have a
mechanical globe injury,
you want to avoid any type of Valsalva that
could increase the intraocular pressure
because that can lead to more damage.
This is another one.
Immediate ophthalmology evaluation for
anything other than that superficial lesion.
And most ophthalmologists are
going to recommend systemic antibiotics,
with some kind of Staph coverage.
So, that could be a drug like levofloxacin
or it could be a fluoroquinolone
along with another drug,
which has gram-positive coverage.
Let’s move on to chemical injury.
We’re moving quickly today.
Just one thing that may
come up on the exam.
Alkali burns, more common than acid burns.
And most of these are
related to work-related accidents.
So, that's why the first step in preventing injury
is appropriate eyewear and safety measures.
Symptoms include swelling and burns in the eyelids.
Your cornea will get cloudy as a
result of the chemical reaction there.
Then the conjunctival injection injected
as the body tries to heal itself.
And you might actually see a completely
white eye due to conjunctival ischemia
if the injury related to the
alkali burn is particularly bad.
The management is, of course,
immediately washing out the eye.
Hopefully, there's an eye station
at the at the site
and the sooner and the more
copious irrigation is better.
But then, once they get
into a medical situation,
like an emergency department,
topical anesthetics with
a lot more irrigation.
And again, this is one for serious burns.
Better to see an eye specialist right away.
The least they are going to recommend is
topical antibiotics with artificial tears
and maybe even more than that
because they might actually
which are always tricky
to use in the eye
and therefore should be
done only by specialists,
should not be done by primary
care in a situation like a burn.
And so, my pearl to everyone,
if you see these cases on a daily basis
or you see one case
every five years,
I feel like it’s just hard to be very
overly conservative with these eye issues
because once you –
it’s a one-time thing to
And once it's lost, many times
it's not coming back.
So, therefore, caution is the watchword
and you should be friendly with an ophthalmologist,
so you can make sure if nothing else,
run these issues by that person.
And if they can’t be reached,
is always at your disposal.
So, let’s look at another subject,
slightly different, maybe not quite
as emergent, but certainly urgent,
is the redeye.
Here we have a nice
example of conjunctivitis.
That’s by far the most
common cause of redeye.
You could see the purulent
drainage on the lashes.
Can I tell just by looking
at this picture whether it's viral
or whether it's bacterial?
It’s hard to say because,
yes, it does have a purulent drainage,
but that's not pathognomonic.
You get some purulence from viruses as well.
But the more copious drainage,
the more severe redness,
the fact that –
especially when it’s
unilateral and not bilateral,
all those may implicate that it’s
a bacterial versus a viral situation.
Now, a focal area of hyperemia,
as you see here,
that may be associated with episcleritis,
which is associated with a variety
of different autoimmune conditions.
So, that might be\ something to
consider in, say, Bissett syndrome,
maybe one of the signs that
the patient is getting Bissett’s.
And scary for patients
and their loved ones,
but generally benign is
Maybe the classic is a
person has a cold,
sneezes a bunch of times,
then goes to bed,
wakes up with this big red bright red
patch in their eye under their conjunctiva.
It’s disconcerting, but usually resolves
over time with no symptoms.
So, I’m going to leave you
with again that clinical pearl that
it's one thing to have a redeye,
but it’s another to have a
red and painful eye.
So, when redness comes with pain,
I consider that an urgent or emergent condition
because it could be a keratitis,
which might be herpetic which can
cause permanent vision loss,
a corneal ulcer which is
a serious diagnosis,
iritis associated with other autoimmune
disorders may exist on its own.
But, again, all of those are good reasons for
referral to ophthalmology on an urgent basis.
I think if you recognize these more serious conditions,
as rare as they might be,
you'll do your patients a world of
good by preserving their vision.
And with that, I just wanted to say thank you
and watch out for those red eyes.