Common Ophthalmic Emergencies

G. D. Khare; R. C. Andrew Symons; D. V. Do

Disclosures

Int J Clin Pract. 2008;62(11):1776-1784. 

In This Article

Orbits

General

The optic nerve and the vascular supply to the eye pass through the orbit, and the orbital contents also include the extraocular muscles. When an orbital problem is suspected the function of all these structures should be evaluated. Optic nerve function should be assessed on the basis of visual acuity, pupillary light reflex and Ishihara colour plate testing. IOP should also be checked. Extraocular movements must be evaluated both for motor nerve palsies and for restriction of motility. Resistance to retropulsion should be evaluated. Proptosis or enophthalmos should be assessed using a Hertel exophthalmometer. Vertical displacement of the globe can also be assessed, and is particularly important in the case of blow-out fractures. If an orbital fracture is suspected, a computed tomography (CT) scan of the orbits with true coronal views is recommended to evaluate the extent of the fracture. If an orbital infection is suspected, the patient's temperature and vital signs should be recorded in addition to CT imaging of the orbits.

Orbital Cellulitis

Orbital cellulitis may present with erythema, tenderness, blurry vision, headache and diplopia. Conjunctival chemosis, purulent discharge, fever, proptosis and restricted ocular motility with pain upon attempted movement may be present. Orbital cellulitis may arise as a complication of orbital trauma, from direct extension of a dental or sinus infection, as a complication of orbital or sinus surgery and from haematogenous spread. Organisms that commonly cause orbital cellulites include Staphylococcus species, Streptococcus species, Haemophilus influenzae, Bacteroides, or gram-negative bacillirods, particularly in trauma cases, direct extension from sinus or dental infection, complications from orbital trauma or eye/paranasal sinus surgery, or spread from the vasculature are all common sources of orbital cellulitis. Mucormycosis must be considered in diabetic or immunocompromised patients, and orbital specimens must be examined when an orbital or ear, nose and throat (ENT) specialist feels that the clinical situation warrants this.

After obtaining history of trauma or focal/and local and systemic illnesses, a complete ophthalmic examination should be performed. One should look for signs of meningitis, afferent papillary defect (APD), limited eye movement, decreased skin sensation, and optic nerve/disc and fundus abnormalities. CT scans of the orbits and sinuses can confirm the diagnosis, and rule out abscesses or foreign bodies which would require surgical management. Laboratory testing of complete blood counts with differential, blood cultures, and gram stain and culture of any drainage can help to target antibiotic therapy.

If orbital cellulitis is diagnosed, an ophthalmology as well as ENT opinion is mandatory, as often the underlying pathology is located in the orbital sinuses. In these cases, broad-spectrum antibiotics, ampicillin/sulbactam or ceftriaxone plus vancomycin, should be administered by intravenous infusion for the first 72 h, and orally for 1 week thereafter. Metronidazole covers anaerobes, and should be considered as well. For patients allergic to penicillins/cephalosporins, vancomycin plus gentamicin or clindamycin plus gentamicin are good substitutes. After initial improvement, amoxicillin/clavulanate or cefaclor can be administered orally for 14 days on an outpatient basis. If symptoms worsen, a follow-up for abscesses, cavernous sinus thrombosis or meningitis should be performed.[6]

Blow-out Fracture

Traumatic blow-out fractures present with pain that, increases upon vertical eye movement, binocular diplopia and crepitus after nose blowing. Epistaxis and ecchymosis may also be present. Enophthalmos may be present after the oedema has resolved. Trauma without a blow-out fracture may present with similar signs, in which case they usually resolve spontaneously in a week.

An examination of the orbital contents as described above should be performed. Signs of subcutaneous emphysema should be noted. The globe should be evaluated carefully for rupture, hyphema, inflammation, iridodialysis, and retinal or choroidal injury. CT scan of the orbit should be obtained to determine the extent of the trauma and to plan the surgical management if this is appropriate.

Nasal decongestant sprays, broad-spectrum oral antibiotics, and ice packs should all be administered. Surgical repair is emergent within 24 h if CT shows entrapped muscle or tissue with signs of diplopia and gastrointestinal (nausea/vomiting) or cardiovascular symptoms (heart block, bradycardia or syncope). If no entrapped muscle is suspected, surgical repair of the orbital fracture can be delayed for 1-2 weeks, and is indicated in cases of cosmetic deformity or diplopia.

Retrobulbar Haemorrhage

Posttrauma retrobulbar haemorrhage presents with pain, tight eyelid, subconjunctival haemorrhage and proptosis resisting retropulsion. Decreased vision, eyelid ecchymosis, limited extraocular motility and increased IOP may also be present. When the vision is threatened, treatment must be commenced urgently, and full work-up delayed until after the patient's vision has been protected.

If IOP is dangerously increased or vision is threatened, urgent surgical intervention in the form of a lateral canthotomy with or without cantholysis is required and can often prevent permanent visual loss.[6]

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