Five Eye Emergencies That Need Quick Referral to Specialist

Marcia Frellick

March 20, 2019

PHILADELPHIA — Not all eye emergencies will be accompanied by pain, but that doesn't mean they aren't serious, said Stephanie Marioneaux, MD, an ophthalmologist in private practice in Chesapeake, Virginia.

Marioneaux will be speaking about eye emergencies and how to predict pathologies from a patient's complaints at the upcoming American College of Physicians Internal Medicine (IM) Meeting 2019.

She will also describe how to gauge the urgency of eye conditions and explain what internists can do to improve outcomes before a patient is referred.

In the case of a traumatic retinal detachment, warning symptoms almost always appear before it advances. Patients might see floaters or specks that seem to drift through the field of vision, flashes of light in one or both eyes, or blurry vision.

Traumatic Retinal Detachment

Traumatic retinal detachments typically don't cause pain unless the patient has experienced a direct blow to the eye.

"If you're always looking for pain, you're going to miss them," said Marioneaux. The extent of visual loss will depend on whether the macula is attached.

The prognosis is better if the macula is "on," she said.

With these detachments, patients should go immediately to a retina specialist, she explained.

Central Retinal Artery Occlusion

The characteristic finding of a central retinal artery occlusion is the cherry-red spot in the middle of the retina. The rest of the retina is milky white with narrowed arteries.

It is a painless cause of profound visual loss, said Marioneaux.

"If you're hypertensive or have had emboli or an irregular heartbeat and you're flipping clots, they can travel to the eye and block off blood vessels," she said.

"The artery brings blood, oxygen, and micronutrients to the eye and when it is occluded, it leads to a major, major loss of vision," she explained.

The condition also comes with an increased risk for stroke.

Ischemic Optic Neuropathy

Patients with ischemic optic neuropathy will have a chalky white swollen optic nerve with blurred disc margins and cotton wool spots, which indicate infarction of the retina.

Typically, patients will suddenly lose vision in one or both eyes.

Ruptured Globe

Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury. It is important to take a good history to identify the source of the trauma.

"You would absolutely not touch it and you would send the patient to the ophthalmologist for surgical repair," Marioneaux said. "You don't want to introduce any bacteria."

You would absolutely not touch it and you would send the patient to the ophthalmologist for surgical repair.

The patient should be instructed not to touch the eye and not to eat or drink anything, and should be sent immediately to the ophthalmologist.

Such ruptures are fairly common; hand-held weed-cutting machines are a big culprit, she said. People might think sunglasses are enough of a barrier but the speed of the projectiles calls for better protective gear, she said.

Bacterial Ulcer

One of the conditions requiring the most urgent referral is bacterial ulcer, Marioneaux told Medscape Medical News.

A patient with a bacterial ulcer will have severe pain and experience some loss of vision, the extent of which will depend on the extent of the infection.

"This is an absolute immediate referral to an ophthalmologist or corneal specialist — same day, same minute," she said. "You have to tailor the medications to the organism identified."

No topical antibiotics should be given until the organism has been isolated, she said.

"These patients are on drops every hour around the clock."

Marioneaux has disclosed no relevant financial relationships.

Follow Medscape InternalMed on Twitter @MedscapeIM and Marcia Frellick @mfrellick

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