1. Ocular Emergencies Pisit Preechawat, MD Department of Ophthalmology, Ramathibodi Hospital

2. Ocular Anatomy

3. 1. Frontal bone 2. Zygomatic bone 3. Maxillary bone 4. Sphenoid bone 5. Ethmoid bone 6. Lacrimal bone 7. Palatine bone 1 2 3 4 5 6 7 Bony Components of Orbit Size 30 x 40 x 45 mm

4. Paranasal Sinus

5. Ocular Anatomy Orbicularis Oculi

6. Ocular Anatomy

7. Ocular Anatomy

8. Ocular Anatomy

9. Extraocular Muscles

10. Optic Nerve

11. Venous System

12. Ocular Emergencies Trauma Non - trauma Blunt trauma Penetrating trauma

13. Retinal arterial Perforation Orbital cellulitis occlusion Ruptured Orbital injury Chemical burns Acute glaucoma Corneal ulcer Sudden congestion Corneal abrasion proptosis Hyphema Intraocular FB Retinal detachment Macular edema ( Immediately ) ( Within a few hours ) ( Within one day ) Acute Eye Conditions Emergency Very Urgent Urgent

14. Ocular condiitons requiring immediate treatment Acute Angle-Closure Glaucoma Central Retinal Artery Occlusion Orbital Cellulitis Cavernous Sinus Thrombosis Endophthalmitis Retinal Detachment Toxic Causes of blindness Nontraumatic Ocular Emergencies Acute Dacryocystitis Acute Dacryoadenitis Acute Hordeolum Preseptal cellulitis Spontaneous subconjunctival hemorrhage Conjunctivitis Bacterial corneal ulcer Viral keratoconjunctivitis Acute hydrops of the cornea Hyphema Uveitis ( iritis & iridocyclitis ) Vitreous hemorrhage Retinal hemorrhage Central retinal vein occlusion Optic neuritis Ocular Emergencies

15. Ocular burns and trauma Ocular Burn Alkali Burns Acid Burns Thermal Burns Burns Due to Ultraviolet Radiation Mechanical Trauma to the Eye Penetrating or Perforating injuries Blunt Trauma to the Eye, Adnexa,& Orbit 1. Ecchymosis of the Eyelids 2. Lacerations of the Eyelids 3. Orbital hemorrhage 4. Fracture of the Ethmoid bone 5. Blowout Fractures of the Floor of the Orbit 6. Corneal Abrasions 7. Corneal & Conjunctival Foreign Bodies Ocular Emergencies

16. Eye Examination Visual acuity External Eye : orbit, periorbital skin, eyelids Confrontation visual fields Ocular motility

17. Anterior Segment Conjunctiva Cornea Anterior chamber Iris Lens Pupils : RAPD Eye Examination

18. A dilated pupil makes it easier to see the optic nerve, macula, and retina - 1% tropicamide ( Mydriacyl ) - 2.5% phenylephrine ( Neo-Synephrine ) Fundus Examination PanOptic Ophthalmoscope Indirect Ophthalmoscope

19. Digital palpation Schiotz tonometer Intraocular Pressure Measurement

20. Ocular Trauma Closed Globe Open Globe Burn Contusion Laceration Laceration Penetrating Perforating Rupture

22. Pain , photophobia , FB sensation, tearing Conjunctival injection, swollen eyelid Corneal Abrasion Epithelial staining defect with fluorescein

24. Corneal Ulcer Hypopyon Eye Shield No patching Topical antibiotics Ophthalmologist referral

25. Conjunctival Foreign Bodies

26. Corneal foreign body with rust ring Rust ring Corneal Foreign Bodies

28. Corneal Foreign Body Removal

30. Traumatic Hyphema : Classification Total IV 1/2 to less than total III 1/3 to 1/2 II Less than 1/3 I No layered blood circulating red blood cells only 0 Size of Hyphema Grade

31. Traumatic Hyphema

35. Full Thickness Lid Lacerations - Gray line - Lash line - Mucocutaneous junction Tear lid margin

36. Laceration of lower eyelid margin Post-operative result following a primary repair Lid Margin Repair

38. Lid Lacerations with tear canaliculi

39. Canalicular Repair

42. Irregular pupil

43. Penetrating / Ruptured Globe

44. Ruptured globe caused by golf ball Penetrating / Ruptured Globe

46. Intraocular or Intraorbital Foreign Bodies

47. Ocular Trauma Traumatic cataract Traumatic mydriasis Traumatic lens subluxation Traumatic lens subluxation

50. Irrigation in case of chemical injury

52. Chemical Ocular Injury : Classification Grade I Grade II Grade III Grade IV

54. Bilateral Alkali Injuries Chemical Ocular Injury

55. Chemical Ocular Injury : Management Corneal Transplantation Keratoprosthesis

58. Non-traumatic Ocular Emergencies

59. The woman suddenly experienced nausea, vomiting, and extreme pain in the left eye while in a movie theater. Her vision has worsened since that time and the eye has become very red. A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting

60. VA - HM Conjunctival injection Hazy cornea Shallow anterior chamber Fixed mid-dilated pupil A 55-year-old woman with a red eye, blurred vision with halos, nausea, and vomiting Acute Angle Closure Glaucoma IOP 56 mmHg

61. Anterior Chamber Depth

62. Reduce the intraocular pressure O.5% Timolol 1 drop 2-4 % Pilocarpine 1 drop every 15 minutes 20% Mannitol 250-500 ml IV drip Acetazolamide 500 mg oral 100% Glycerin 1 cc/kg Consult ophthalmologist Acute Angle Closure Glaucoma

63. A 60-year-old woman with acute, painless loss of vision in the right eye Visual acuity CF – LP in 90% of cases Opaque white retina and attenuated vessels Central Retinal Artery Occlusion

64. Treatment must be initiated immediately. Ocular massage Inhaled carbogen ( 95% O2 and 5% CO2 ) Reduced intraocular pressure Central Retinal Artery Occlusion Consult ophthalmologist immediately Anterior chamber paracentesis Direct infusion of t-PA or urokinase in the ophthalmic artery

65. A 40-year-old man with left eyelid edema and pain ( worse on eye movement )

67. Broad spectrum intravenous antibiotics CT scan orbit Ophthalmology & ENT consultation Orbital Cellulitis Subperiosteal abscess

68. Preseptal Cellulitis

69. Endophthalmitis

70. Urgent Neuro-ophthalmology

71. A 36-year-old-woman with subacute visual loss in right eye and pain on eye movement VA 20/200, 20/25 RAPD +ve OD VF central scotoma OD Retrobulbar optic neuritis

72. A 55-year-old man with HT and acute visual loss in RE VA 20/100, 20/20 RAPD +ve RE Nonarteritic anterior ischemic optic neuropathy ESR 10 mm/hr

73. A 73-year-old woman with acute visual loss of right eye, headache, anorexia and weight loss VA 10/200, 20/25 RAPD + ve RE ESR 94 mm/hr, high level of C - reactive protein Arteritic anterior ischemic optic neuropathy

74. Pathology : Giant Cell ( Temporal ) Arteritis

75. A 35-year-old man with left painful third nerve palsy VA 20/25, 20/30 Dilated, nonreactive pupil LE

76. A 35-year-old man with a suspicious of aneurysmal third nerve palsy Conventional CT scan or MRI are not the procedure of choice High false negative rate 12 – 40 % Magnetic resonance angiography (MRA) Computed tomography angiography (CTA) Overall sensitivity up to 97 %

77. A 35-year-old man with a suspicious of aneurysmal third nerve palsy

78. A 40-year-old woman with sudden onset of left third nerve palsy, visual loss and severe headache What is the diagnosis? VA 20/30, LP +ve RAPD LE

79. Pituitary Apoplexy Characterized by sudden visual loss, headache, and ophthalmoplegia secondary to rapid expansion of pituitary macroadenoma into the suprasellar space and/or cavernous sinus Commonly results from hemorrhage into a pre-existing pituitary mass

80. A 17-year-old man with right blured vision after minor blunt trauma. VA 20/32, 20/20 + ve RAPD RE Normal fundi RE LE

81. A 16-year-old man with head injury and left blured vision after falls from height VA 20/30, LP + ve RAPD LE Normal fundi

82. Traumatic Optic Neuropathy : Classification and Mechanisms Direct injury - Penetrating injury from knife, projectile - Injury from fractured bone - Avulsion, transection Indirect injury - Contusion with transmission of force through bone - Compression secondary to orbital hemorrhage or intrasheath hemorrhage

83. Clinical Features of Traumatic Optic Neuropathy Most commonly unilateral May be overlooked in setting of significant globe or maxillofacial trauma Reduced visual acuity ( NLP to 20/20 ) Visual field defect : No pathognomonic defect Normal optic disc with development of optic atrophy

84. Medical Management Options Steroids : Controversial - Thought to limit free-radical amplification of the injury response - Dosages ( low, high, mega) - May be harmful Observation : 57% of untreated patients shown to have 3 lines or more acuity improvement

85. Surgical Management Options Lateral canthotomy and cantholysis for orbital hemorrhage Surgical decompression of the optic nerve within its canal There is no defined standard protocol of treatment for indirect optic nerve injury .

86. Thank you for your attention