Ophthalmological emergencies

13.1 Ophthalmological emergencies



Toby Fogg




Essentials



1 A history of contact lens use should always be sought.

2 Visual acuity should always be assessed.

3 Neonatal conjunctivitis may have severe sequelae if inadequately treated.

4 The suspicion of keratitis should prompt urgent ophthalmic review.

5 The distinction between orbital and preseptal cellulitis should always be made.

6 Local anaesthetic drops should never be given to a patient to take home.


Introduction


Few ophthalmological emergencies relate exclusively to children. Although the pathology may be the same, the general approach, examination and compliance with treatment is very different depending on the age and development of the child. Also, the long-term sequelae of serious eye injury or disease are much greater.



History


As with other paediatric encounters, it is important to gain the child’s confidence in you whilst obtaining the history from the parents or carers. A detailed history should be obtained from an adult witness. If this is unavailable, injury will be the likely cause of a painful red eye. Other conditions presenting with a red eye are listed in Table 13.1.1. Always enquire about the use of contact lenses or glasses.





































Table 13.1.1 Differential diagnosis of the red eye
Normal visual acuity  
Conjunctivitis (bacterial, viral, allergic, chemical) Gritty, itchy, injected conjunctiva, discharge
Foreign body Pain, grittiness, epiphoria, photophobia
Episcleritis Mild pain, localised conjunctival injection
Scleritis Severe pain, diffuse conjunctival injection
Subconjunctival haemorrhage Consider trauma or pertussis
Reduced visual acuity  
Corneal abrasion Pain, grittiness, epiphoria, photophobia. Corneal defect seen with fluorescein staining
Keratitis Photophobia, epiphoria, ciliary injection, flare in anterior chamber, corneal infiltrate
Corneal ulcer Photophobia, epiphoria, corneal injection, flare in anterior chamber, defect on fluorescein staining. History of contact lens use?
Anterior uveitis Photophobia, epiphoria, ciliary injection flare in anterior chamber, miosis, posterior synechia


Examination


The approach to the examination of a paediatric eye may differ from that of an adult in that an opportunistic strategy should be taken. Leave touching the child until last, particularly if it will result in fear, pain or discomfort.


Some form of assessment of acuity must be made. In pre-verbal children, assess their ability to fix and follow interesting objects and then reach for them. In older children, monocular testing should be carried out using picture cards, single letter matching or a standard Snellen chart. Use of the slit lamp is not essential for a detailed examination, but even small children may co-operate if they remain seated on their parent’s knees.


If the child is compliant, a logical sequence of examination would be from outside to inside thus:


• visual acuity – using Snellen chart with letters or pictures;

• extraocular movements – follow a finger, a small toy or a face;

• visual fields;

• lids, lashes and lacrimal apparatus;

• conjunctiva and sclera;

• cornea;

• anterior chamber;

• pupil and iris;

• lens;

• red reflex, posterior chamber and retina.

All drops will sting, except for fluorescein. However, once the pain has subsided, the effects of local anaesthetic may allow for a much more meaningful examination than would otherwise have been possible. If, however, this remains impossible, consideration should be given to examination under anaesthetic.



Eyelid disorders



Blepharitis


Blepharitis is an inflammatory process of the eyelids that is characterised by crusting at the base of the eyelashes. There may be oedema of the lids themselves and occasionally the conjunctiva is also injected. Staphylococci are the usual organisms. Treatment should involve the removal of the crusts using a warm flannel, cleansing with dilute baby shampoo and application of antibiotic ointment to the lid margin.



Hordeolum (stye)


A hordeolum is an acute infection, usually staphylococcal, of an eyelash follicle. It causes a small, tender swelling, often with a head of pus, which is seen at the lid margin. Treatment is with warm compresses and chloramphenicol ointment until resolution occurs.



Chalazion (meibomian cyst)


This is caused by inflammation of the lipid-secreting meibomian glands of the lid, probably due to ductal obstruction. It presents as a slowly progressing, mildly painful red lump in the eyelid. Most settle with conservative treatment, namely warm compresses for 10 minutes four times a day with light massage and chloramphenicol ointment for up to 4 weeks. If this treatment fails, or the cyst is excessively large causing visual disturbance, it can be incised. It may become complicated by preseptal cellulitis that may require systemic antibiotics.



Disorders of the lacrimal apparatus



Nasolacrimal duct obstruction


This condition occurs in 6% of infants and almost invariably resolves within the first year. It may cause epiphoria (watering), a mucoid discharge or some erythema of the lids. There may be a minor mucopurulent discharge and rarely a bluish palpable mass will be seen overlying the drainage system, which represents a dacryocele. Treatment of simple obstruction consists of gentle massage four times a day and cleansing. Should spontaneous resolution not occur, the child should be referred for probing of the duct after 6 to 12 months of age. If there is a mucopurulent discharge, topical antibiotics should be added for 2 weeks.



Dacryocystitis


This is defined as infection of the nasal lacrimal duct and presents with pain, redness, swelling and tenderness of the overlying skin and the adjacent nasoperiorbital area. There may also be tearing, discharge and fever. Pressure over the lacrimal sac may express pus from the punctum. This should be sent for culture. Staphylococcus aureus and Staphylococcus epidermidis are the commonest organisms. Treatment should be with cefalexin orally or cefazolin intravenously (IV) if unwell. Gentle massage in the more minor cases may well aid in clearing the infection and unblocking the duct, as dacryocystitis is invariably associated with ductal obstruction that may be congenital or acquired. Probing or irrigation of the lacrimal system should be avoided in the acute setting and in infants less than 6 months old. Complications include preseptal cellulitis; orbital cellulitis and cavernous sinus thrombosis occur very rarely.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Ophthalmological emergencies

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