Ocular Emergencies

Chapter 27 Ocular Emergencies



Darcy Egging


As in all other emergency situations, potentially life-threatening conditions must be addressed prior to the assessment and management of ocular problems. However, ocular problems are high priority because of the potential effect on vision.



Determining Visual Acuity


Visual acuity is considered a “vital sign” for patients with ocular problems and should be obtained on all patients presenting with a visual complaint. The exception to this rule is the patient with a chemical burn to the eye; this is a true medical emergency and the nurse should immediately initiate treatment in the form of eye irrigation prior to measuring visual acuity.



• Determine visual acuity before manual eye examination because manipulation increases blurring and decreases visual acuity.


• Consider instilling a topical anesthetic agent before examination to facilitate obtaining visual acuity.



• Measure visual acuity with and without corrective lenses.


• Use the Snellen chart, placed at a distance of 20 feet, to test the affected eye first, then the unaffected eye, and finally both eyes.

• Use the “E Chart” with patients who are illiterate or non-English speaking.

• If the patient is unable to see the Snellen chart, assess visual acuity by walking toward the patient holding up several fingers. Stop walking when the patient is able to tell how many fingers are being held up. Document the number of fingers and the distance from the patient (e.g., “three fingers at 15 feet”). Near-vision cards are also available for nonambulatory patients.


• If the patient is unable to see fingers, assess for the patient’s perception of light and dark.


Do not instill topical ocular agents if ruptured globe is suspected.



Contact lenses should be removed prior to eye examination other than for visual acuity.



Conjunctivitis (Pink Eye)


Acute conjunctivitis is an infection of the conjunctiva, the membrane that lines the eyelid and sclera. Causes of conjunctivitis include bacterial, viral, and fungal infections and allergic and chemical irritation.1



Signs and Symptoms




• Eyelids “crusted” shut upon awakening in the morning


• Sensation of foreign body in the eye


• Conjunctival erythema


• Purulent drainage (bacterial infection)


• Serous discharge (allergic or viral cause)


• Pruritus (allergic conjunctivitis)



Diagnostic Procedures




• Diagnosis based on clinical examination


• Culture discharge only if conjunctivitis is severe (“waterfall” discharge of gonorrhea), chronic, or unresponsive to treatment.



Therapeutic Interventions




• Antibiotic ophthalmic drops or ointment for bacterial infections.


• Cool compresses and decongestants for allergic conjunctivitis.


• If conjunctivitis is gonococcal, consider that the patient may also have chlamydial conjunctivitis; systemic therapy and appropriate referrals will also be needed.


• Treat chemical conjunctivitis as a chemical burn with immediate eye irrigation.



Patient Education




• Bacterial and viral conjunctivitis are highly contagious; teach the following infection control measures:


• Practice frequent hand washing using good technique.

• Keep children home from school until infection has cleared.

• Do not share objects such as towels, washcloths, and pillows that may come in contact with discharge.

• Stay out of swimming pools until symptoms have resolved.

• Do not handle food while infection is present.

• Discard eye make-up.

• Warm soaks may help to gently remove crusted exudates from eyelids and lashes after sleep.


• Cool compresses can be applied to eyelids for comfort and to decrease swelling.


• Wear sunglasses to decrease photophobia.


• Do not wear contact lenses or eye makeup until symptoms have resolved.


• Follow up with health care provider or ophthalmologist in 2 to 3 days.




How to Instill Ophthalmic Medications



Ophthalmic Drops




1. Explain the procedure to the patient.


2. Pull the lower eyelid down.


3. Have the patient look up.


4. Instill one or two drops of solution into the cul-de-sac (the center of the lower lid).


5. Have the patient blink gently to distribute the solution.


6. Instruct the patient not to squeeze the eyelids shut tightly; this will cause the solution to leak out.



Ophthalmic Ointment




1. Explain the procedure to the patient.


2. Pull the lower eyelid down.


3. Have the patient look up.


4. Apply ointment in a 1-cm line into the inner aspect of the lower lid.


5. Have the patient blink to distribute the ointment.


6. Instruct the patient not to squeeze the eyelids shut tightly; this will expel the ointment.



Infections of the Eyelids and Cornea


Infections of the eyelids (i.e., blepharitis, hordeolum, chalazion) or the cornea (keratitis) are not uncommon complaints of patients presenting to the emergency department. The most likely causative pathogen for these infections is Staphylococcus aureus. Table 27-1 summarizes the signs and symptoms and therapeutic interventions for these ocular infections.



TABLE 27-1 EYELID AND CORNEAL INFECTIONS

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Ocular Emergencies

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