Eye Emergency Manual: An illustrated guide

Pain Management Network

aci.health.nsw.gov.au

Ophthalmology Network

Eye Emergency Manual

An illustrated guide

aci.health.nsw.gov.au

THIRD EDITION, DECEMBER 2023

This information is not a substitute for healthcare providers’ professional judgement.

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Title Eye Emergency Manual, 3rd Edition

Published December 2023

Next review 2028

Produced by ACI Ophthalmology Network

Preferred citation

NSW Agency for Clinical Innovation. Eye Emergency Manual, 3rd Edition.

Sydney: ACI; 2023.

TRIM ACI/D23/169 SHPN (ACI) 230806 ISBN 978-1-76023-644-1

ACI_8666 [11/23]

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Eye Emergency Manual December 2023

Background 1

Introduction 3

Anatomy 4

Anatomy terms 5

Eye assessments 6

History to ascertain 7

Assessing the severely injured patient 15

Paediatric assessment 16

Examinations 18

Examination essentials 18

General inspection and assessment

of periocular and globe trauma 20

Visual acuity 23

Pupil examination 27

Visual field, eye movements

andeyelid examination 29

Eyelid eversion 33

Special eye examinations 34

Direct ophthalmoscope 34

Checking intraocular pressure 35

Slit lamp 37

Eye referrals and discharge advice 40

Traumacommunication checklist 40

Acute visual disturbance

communication checklist 40

Red eye or eyelid

communication checklist 40

Visual requirements for driving 41

Prevention of visual impairment 42

Eye trauma 43

Blunt ocular trauma 44

Chemical burns 46

Closed globe injury 49

Flash burns 51

Lid laceration 52

Non-accidental injury (NAI) 54

Open globe injury

(penetratingeye injury) 55

Orbital fracture 57

Retrobulbar haemorrhage

(orbital compartment syndrome) 59

Acute visual disturbance 61

Third (3rd) cranial nerve palsy 62

Fourth (4th) cranial nerve palsy 63

Sixth (6th) cranial nerve palsy 65

Central retinal artery occlusion (CRAO) 66

Central retinal vein occlusion (CRVO) 68

Central serous chorioretinopathy 69

Dry eye/exposure keratopathy 70

Giant cell arteritis (GCA)/anterior

ischaemic optic neuropathy (AION) 72

Idiopathic intracranial hypertension (IIH):

transientvisual obscuration 73

Intermittent angle closure/

acuteangle closure 75

Lens subluxation 76

Contents

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Eye Emergency Manual December 2023

Macular haemorrhage in wet

age-related macular degeneration 77

Macular pathology 78

Migraine 78

Myasthenia gravis 79

Optic neuritis 80

Posterior vitreous detachment (PVD) 8 1

Retinal tear or detachment 83

Thyroid eye disease 84

Transient ischaemic attack

(amaurosis fugax) or retinal emboli 85

Visual pathway lesion 87

Vitreous haemorrhage 87

Acute red eye or eyelid 89

Acute red eye overview 90

Acute angle closure crisis 91

Acute blepharitis 93

Allergic conjunctivitis 94

Iritis (anterior uveitis or an anterior

chamber inflammation) 95

Bacterial or acanthamoebal ulcer 96

Bacterial conjunctivitis 97

Chalazion/stye 98

Corneal or conjunctival foreignbody/

corneal abrasion 100

Ectropion 103

Entropion 104

Episcleritis 105

Eyelid lesion 106

Herpes simplex virus keratitis

(HSV/HSK) 106

Herpes zoster ophthalmicus (HZO)/

shingles 108

Hyphaema 109

Hypopyon 111

Marginal keratitis 112

Neovascular glaucoma 113

Ophthalmia neonatorum

(neonatal conjunctivitis) 114

Preseptal cellulitis

(periorbital cellulitis) 116

Pterygium 118

Scleritis 119

Subconjunctival haemorrhage 121

Trichiasis 122

Viral conjunctivitis 123

Treatments 125

Ocular drugs 126

How to put in eye drops 130

References 131

Appendix: Evidence base 133

PubMed search terms 133

Google search terms 133

Inclusion and exclusion criteria 133

Bibliography 133

Glossary 135

Eye Emergency Manual December 2023

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Background

The Eye Emergency Manual (EEM) is designed for medical, nursing and alliedhealth

staff in emergency departments and critical care, and for rural general practitioners.

The EEM has not undergone a formal process ofevidence-based clinical practice guideline development;

however, it is the result of consensus opinion determined by relevant experts. The EEM is not a denitive

statement on correct procedures; rather, it is a general guide to be followed subject to clinical judgement.

The EEM is based on the best information available at the time of writing.

The EEM was rst released in 2007 and last updated in 2009. The current review was undertaken by the ACI

Ophthalmology Network with oversight by a clinical working group led by Dr Parth Shah.

Method

The EEM was reviewed formally by members

of a working group, including clinicians in

ophthalmology, optometry, orthoptics, emergency

and critical care, and rural general practice

across NSW. Data for theEEM were drawn from

a literature search, consensus expert opinion of

the working group and consultation.

Rapid, targeted literature searches of PubMed

were conducted in June and July 2023. Searches

were related to: eye diseases OR eye injuries

AND emergency treatment AND guidelines

OR principles.

Grey literature searches were completed using

Google and Google Scholar.

Refer to "Appendix: Evidence base" for search

terms and reference list.

Consultation

The following groups were consulted for this

revision:

• Members of the working group

(as listed under ‘Acknowledgements’ below)

• ACI Networks

• Survey respondents

The Eye Emergency Manual is endorsed by the

Australian College of Emergency Nursing and

the Save Sight Institute, University of Sydney.

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Acknowledgements

Parth Shah, Ophthalmologist, Prince of Wales

Hospital and Sydney Children’s Hospital

Claire Cuppitt, General Practitioner

Lin Davis, Nurse Educator, Rural Critical Care,

Hunter New England LHD

Michael Golding, Emergency Physician,

Prince of Wales Hospital

Paula Katalinic, Optometrist and Professional

Services and Advocacy Manager, Optometry

NSW/ACT

Yves Kerdraon, Ophthalmologist, Sydney

Hospital/ Sydney Eye Hospital and

ConcordHospital

Kerrie Martin, Ophthalmology Network and

Clinical Genetics Network Manager, Agency for

Clinical Innovation

Erin McArthur, Project Ofcer, Agency for

Clinical Innovation

Peter McCluskey, Professor and Chair of

Ophthalmology, University of Sydney and

Director, Save Sight Institute

Joanna McCulloch, Clinical Nurse Consultant

Ophthalmology, Sydney Hospital/Sydney

Eye Hospital

Danielle Morgan, Acting Deputy Head of

Orthoptic Department, Sydney Hospital/Sydney

Eye Hospital

David Murphy, Director of Emergency Medicine,

Prince of Wales Hospital

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Introduction

The EEM is designed to provide a

quick and simple guide to recognising

important signs and symptoms, and

assisting with the management of

common eye emergencies. The EEM

will also assist with triaging patients

to appropriate care.

How to use this resource

For ease of use, the EEM has a large

amount of graphic content and is divided

into basic ophthalmic diagnostic

techniques/treatment and management

of common eye presentations.

Each condition includes

information about:

• immediate action (if any)

• history

• examination

• treatment

• communication checklist(s).

Each condition has red ags used

to increase the triage weighting or

indicate urgent ophthalmic referral

with an explanation of relevance.

Anatomy

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Anatomy

Anatomy terms

Useful terms when describing an

eye lesion

• Right vs. left

• Globe vs. eyelids vs. periocular region

• Nasal (medial) vs. temporal (lateral)

• Superior vs. inferior (relative to the pupil)

• Corneal clock hours (as seen by the examiner,

e.g. 3 o’clock is the temporal limbus of the

left eye)

• Surface area of the cornea, e.g. 30% ulcer

Useful pathological terms

• Ulcer (loss of epithelium from the cornea,

conjunctiva or eyelid skin)

• White dot on the cornea or opacication: try to

differentiate between inltrate (abscess/

infection), long-standing scar, foreign body or

hazy cornea

• Redness on the conjunctiva: try to differentiate

between conjunctival injection, subconjunctival

haemorrhage and inamed conjunctival lesion,

e.g. pterygium or pingueculum

• Laceration (partial- or full-thickness if involving

the cornea, conjunctiva, sclera or eyelid)

• Blunt or sharp eye injury (depending on the

object used)

• Penetrating wound (which enters the full

thickness of the cornea or sclera)

• Leaking or sealed wound: use Seidel test to

determine if a penetrating wound is

actively leaking

Eye assessments

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Eye assessments

History to ascertain

Basics

• Age

• Allergies

Reason for presentation

• Visual loss

• Eye pain

• Eye redness

• Trauma

• Foreign body

• Chemical injury

• Flashes/oaters

• Diplopia (double vision)

If a chemical injury is

suspected, postpone

further history-taking or

examination and

immediately begin

irrigation of the eye(s).

Mode of presentation

• Post trauma

• Self-presenting due to symptoms

• Via general practitioner (GP)

or optometrist

Past medical history

• Including microvascular

risk factors

• Social history

• Medications

Ophthalmic background

• Glasses: distance/reading/

bifocals/multifocals

• Contact lenses

• Eye surgery (when was it done,

where and by whom)

• Eye laser (what was it for)

• Eye drops (prescribed or

over-the-counter)

• Whether the patient is known to

anophthalmologist or

ophthalmology department

• When, where and who last saw the

patient and what problems were

being managed

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Consider the following when conducting an

eye assessment:

• Demographics are crucial to the diagnosis of

many ophthalmic conditions. An ophthalmologist

will often ask you to go back and clarify a

patient’s age before moving on to the details of

the presentation.

• The most common reasons for patients to

present with ophthalmic problems are listed

above. Determining which of these is relevant to

the patient will focus your clinical assessment

and discussion with the ophthalmologist. Be

aware that this is a simplied approach and

there may be multiple reasons, such as visual

loss following trauma, or there may be

another symptom.

• Patients often confuse optometry and

ophthalmology, so be careful to make this

distinction yourself. If the patient refers to

advice given by their ‘eye doctor’ clarify exactly

who they mean and what advice was given.

Take note of drops that may have been

prescribed by a GP or an optometrist in the

recent past. Steroid drops are occasionally

prescribed for red eyes but can cause

blinding complications when used

inappropriately. Steroid eye drops should

only be prescribed following a

comprehensive ophthalmic examination

and in situations where close ophthalmic

follow-up can be provided.

• Ask if the patient drives and in what capacity.

• Ask if the patient is a carer for someone else, or

if they are cared for themselves.

Notes

You must specically ask if the patient has

had any eye surgery, laser or injections.

Remember that the patient may not volunteer

the information because they may not deem

it relevant, but it may be crucial to diagnosis.

Because many ophthalmic procedures are

done on an outpatient or day surgery basis,

with regional anaesthetic, and can be very

rapid, patients may omit to mention them

simply because they have forgotten. This is

particularly the case if the procedure was

performed many years ago

without complication.

Intravitreal injections are the modern

standard of care for certain types of

macular degeneration, diabetic

macular oedema and other

ophthalmic conditions, and hence are

very common. This treatment entails

regular injections, sometimes

monthly, and prevents blindness in

many thousands of patients. It also

exposes patients to the rare but

devastating complication of

intraocular infection

(endophthalmitis) following injection.

Any patient presenting with

ophthalmic symptoms following an

intravitreal injection requires urgent

ophthalmic review.

Although the most common ophthalmic

operation is cataract surgery, there are many

different operations that a patient may have

had, including retinal detachment surgery,

surgery for glaucoma or corneal

transplantation. It is very helpful if the

patient can tell you what they have had, so

try to elicit these details.

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Visual loss

• When it occurred

• What the patient was doing

• What has happened since the visual loss

Ask the patient to describe the following:

• Total ‘black out’ or ‘blurry’

• Intermittent or constant

• Whole or part of the visual eld

• One or both eyes

• If the eyes are painful or painless

• Are the eyes red or white

• Preceding ashes/oaters OR brief

episodes of visual loss

• Any similar previous episodes

Consider whether the patient has associated

symptoms, such as:

• Headache

• Nausea or vomiting

Notes

Visual loss is potentially very serious

and should be accorded an

appropriate level of concern.

Of the numerous potential causes of visual

loss, some can be elucidated with the above

questions.

For example:

• Rapid, painful visual loss in a red eye with

associated headache and vomiting may be

due to an angle closure crisis (angle

closure glaucoma).

• Sudden vision loss in one eye that was

preceded by intermittent episodes in the

hours or days prior may be amaurosis

fugax, heralding an impending

cerebrovascular accident or anterior

ischaemic optic neuropathy due to giant

cell arteritis (GCA).

• Visual loss in one or both eyes that is

accompanied by headache may be due to

GCA or elevated intracranial pressure.

• Visual loss preceded by ashes/oaters

may be due to a retinal detachment.

If you are concerned about a neurological

cause for visual loss, it is reasonable to

proceed with appropriate neuroimaging prior

to contacting an ophthalmologist. An

ophthalmologist may help with the diagnosis

of some neurosurgical emergencies but

cannot treat them.

Flashes/oaters are a common reason for

presentation and may indicate the presence

of a retinal tear or may be innocuous. There is

no way to make this distinction from the

patient’s history. Therefore, a patient with

ashes/oaters should be regarded as

having a retinal tear until proven otherwise.

This requires a detailed examination of the

peripheral retina by an ophthalmologist with

specialised equipment and is beyond the

scope of an emergency department

(ED) assessment.

Patients may not notice loss of vision in one

eye and only come to realise this sometime

later when the good eye is covered for

another reason. This is not common, but can

occur once other causes of acute visual loss

have been excluded.

Abrupt vision loss in any patient over

50 years of age mandates

consideration of giant cell arteritis

(GCA) (see next).

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Double vision (diplopia)

• Double vision (diplopia) can be a confusing

symptom for both the patient and the doctor.

Keep it simple by working through the

following questions:

• Is it only present with both eyes open?

• Is it present if one eye is closed? If so,

which eye?

If double vision is only present with both eyes open,

consider whether:

• the two images are side-by-side, on top of each

other, or vertically displaced

• the double vision resolves if the patient looks in

a particular direction

• the double vision gets worse (greater separation

between the images) in another direction.

Notes

• Consider whether it is truly double vision,

as opposed to one eye’s blurred image

superimposed on the other eye’s clear

image. This would suggest that visual loss

or blurring is the real issue.

• Binocular diplopia occurs if the double

vision is only seen with both eyes open.

This usually means that the eyes are

misaligned due to an imbalance of the

extraocular muscles.

Binocular diplopia is an emergency

as it may indicate a cranial nerve

palsy due to intracranial pathology,

for example, a third cranial nerve

palsy caused by an aneurysm of the

posterior communicating artery. Pay

close attention to the presence of

eyelid ptosis, pupil changes,

concurrent headache and other

neurological symptoms, and proceed

with urgent neuroimaging if you

deem it appropriate.

Binocular diplopia in any patient over

50 years of age mandates

consideration of giant cell arteritis

(GCA) (see next).

Other common causes of diplopia are other

cranial nerve palsies, myasthenia gravis,

thyroid eye disease and periorbital fractures,

so look for the clinical signs associated with

these disorders.

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Painful or red eyes

Ask the patient the following questions:

• Has the patient had recent intraocular

surgery, laser or intraocular injections?

• Does the patient wear contact lenses?

If so, has the patient been swimming with,

sleeping with or overwearing the

contact lenses?

• Does the patient have decreased vision?

• Did the patient experience any prior

trauma, foreign body or ash from welding?

• What is the duration of symptoms?

• Does it affect one or both eyes? One eye

then the other?

• Are the eyes itchy?

• Is there discharge?

• Do family members or other contacts of the

patient have a red eye?

• Has the patient experienced any prior

similar episodes? If so, were they

investigated and what was the cause,

if known?

• Has the patient had prior herpetic

eye disease?

• Does the patient have any cold sores or

need for prior acyclovir?

• Does the patient have any systemic

symptoms such as rash, arthritis

or urethritis?

Notes

An urgent ophthalmic referral is

mandatory if a patient presents with

symptoms following a recent

ophthalmic procedure, especially any

eye surgery or intravitreal injection

(injection into the eye).

Similarly, any contact lens wearer

with red or painful eyes (or visual

changes) warrants an urgent

ophthalmic review.

Discharging, red eyes in a neonate

within one month of birth is an

ophthalmic emergency and requires

immediate input from ophthalmology,

paediatrics and infectious diseases.

• Red, painful eye(s) associated with visual

loss may be due to acute angle closure

crisis, corneal infection, severe

intraocular inammation, (e.g. iritis) or

intraocular infection (endophthalmitis).

• The presence of discharge usually

indicates a viral, bacterial or

allergic conjunctivitis.

• Herpetic eye disease tends to be

recurrent and can be associated with

signicant corneal scarring and visual

impairment. Patients may be aware of the

presence of corneal scars or that they

needed topical (or systemic) antivirals in

the past. Patients with herpetic eye

disease often need chronic low-dose

topical steroids or prophylactic systemic

antivirals, which may be a clue to

their diagnosis.

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Trauma or chemical injury

If a chemical injury is suspected, postpone

further history-taking or examination and

immediately begin irrigation of the eye(s).

Ask the patient the following questions:

• What time did the trauma/chemical

injury happen?

• Where did it happen?

• What was the mechanism?

• If a chemical injury is suspected, what was

the chemical?

• If a foreign body is suspected, what does

the patient think it might be?

• Was the patient doing any grinding or other

industrial activities before eye symptoms?

• Was any plant or organic material involved?

• Were the patient’s glasses or any protective

eyewear worn?

• How has vision been affected since

the injury?

Figure 1. White blow-out fracture.

Notes

Ophthalmic trauma and chemical injuries are

potentially blinding. Because of this, the

normal sequence of history and examination

is sometimes suspended.

In the case of a chemical injury,

check the pH and immediately begin

copious irrigation until the pH is

normal. This is one situation in which

you do not need to check visual

acuity in the acute stage. Find out

what the chemical was, whether it

was acid or alkali and liaise with the

Poisons Information Centre (131 126)

for further information.

Globe ruptures can occur following

serious or seemingly innocuous

injuries and from both blunt or

penetrating trauma. If you suspect a

globe rupture, stop examining the

patient and immediately apply a clear

shield over the eye. Do not clean the

eye or perform any manipulation, as

this can worsen the injury. However,

you must still check the visual acuity.

Retrobulbar haemorrhage is usually

dramatic and readily apparent from

an examination. It is a clinical

diagnosis, and you must check visual

acuity. If suspected, liaise urgently

with an ophthalmologist who can

perform emergency lateral

canthotomy and lower lid

cantholysis. This can sometimes also

be performed by plastic and

maxillofacial surgeons or ED

physicians, depending upon the skill

set possessed.

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• If the eye has been scratched, determine

whether organic material was involved as

this increases the risk of infection,

especially fungal keratitis.

• Always document the mechanism of any

eye injury carefully, as it may have

medicolegal implications. If there is a

chemical injury, document whether the

exposure happened at work or in

the home.

• Be specic about the type of eye

protection worn at the time of injury,

including the patient’s own glasses,

specialised protective spectacles or

protective goggles.

• Glasses worn at the time of trauma can

shatter and pieces of the lens or frame

may contribute to ocular injury. Maintain a

low threshold of suspicion for penetrating

eye injury and, if possible, ask to examine

the glasses that may have been brought to

hospital with the patient.

Figure 2. Swollen optic disc and

haemorrhage.

Haemorrhage

Swollen optic disc

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AION due to giant cell arteritis

Consider the following in determining if the patient

has giant cell arteritis (GCA):

• Abrupt, painless loss of vision in one or

both eyes

• Brief, transient visual loss in hours or days prior

• Double vision

• Headache (classically frontotemporal)

• Jaw or tongue claudication

(worse with chewing or talking)

• Discomfort on brushing hair over one or

both temples

• Weight loss

• Anorexia

• Polymyalgia rheumatica symptoms (pain and

stiffness in pelvic or shoulder girdles)

Notes

Suspect giant cell arteritis (GCA)

inany patient over 50 who presents

with visual changes or a cranial

nerve palsy.

• You may have already considered GCA if

the patient has visual loss or diplopia, but

take the opportunity to consider the

diagnosis again prior to contacting

an ophthalmologist.

• GCA can present insidiously and rapidly

progress to bilateral complete blindness,

in some cases despite

adequate treatment.

• The diagnosis of GCA is largely clinical, i.e.

it is based on history and supplemented

with inammatory markers, and only later

by a temporal artery biopsy. Treatment is

usually undertaken in the presence of

compelling history, regardless of

inammatory markers.

• If you suspect GCA, liaise urgently

with an ophthalmologist. Referrals to

endocrinology or rheumatology may also

be appropriate in certain

clinical scenarios.

• Jaw (or tongue) claudication can be

differentiated from other causes of dental

or temporomandibular pain by determining

that (as with all claudication) there is no

pain at the beginning of mastication, and

that pain develops after a specic amount

of time, abates after cessation of chewing

and recurs upon resumption.

• Document symptoms specically and in

point form, (e.g. ‘no headache, no jaw

claudication, no tongue claudication’)

rather than simply writing ‘no GCA

symptoms’ as this might be

challenged subsequently.

• The relevant clinical signs to elicit on

examination in suspected GCA are:

tenderness over the supercial temporal

arteries or paucity of pulsation on one or

the other side and the presence of a

relative afferent pupillary defect (RAPD).

In acute GCA, the optic disc may be pale

and swollen, and while an effort may be

made to visualise the optic disc, this is

normally outside the scope of an

ED examination.

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Assessing the severely

injured patient

Although life-threatening injuries take priority over

the assessment of the eye, it is not acceptable for

severe ocular injury to go unrecognised in a multi-

trauma patient once life-threatening issues have

been stabilised.

There are two main reasons for including an eye

assessment in the assessment of relevant

trauma patients:

• Firstly, damage to the eye can become the

dening injury for a patient who has survived

severe trauma, irrespective of the other injuries

they sustained. Hence, it is important to be

aware of these injuries early so that they can be

addressed appropriately.

• Secondly, although rare, some ocular injuries are

amenable to timely intervention that can

sometimes restore vision, e.g. retrobulbar

haemorrhage and chemical injury. Missing these

entities can contribute signicantly to a

patient’s morbidity.

Technique

Checking visual acuity in recumbent or restrained

patients or those in cervical collars can be difcult,

but this is vital if an ophthalmic injury is suspected.

Strategies include the following:

• Use another staff member to occlude the other

eye or hold a pinhole.

• Lower the patient’s bed without compromising

immobilisation of the spine.

• Hold a 3m chart above the patient’s bed. Ensure

your safety rst and foremost and adhere to

work health and safety regulations.

• Permanently tape a 3m or 6m chart to the

ceiling after measuring the distance between

the bed (putative position of the eyes) and the

ceiling. The acuity readings can be calibrated

based on the distance you have measured, e.g.

an eye that just sees the largest ‘E’ on a 6m

chart (labelled ‘60’) from a 2m distance should

be recorded as ‘2/60’.

While it is not possible to check visual acuity in

obtunded or intubated patients, you must still

undertake the following:

1. Perform a general inspection of the globe:

− check the integrity of the globe for rupture

− examine without putting pressure on the eye

− check for retrobulbar haemorrhage

− check for a bulging, tense, proptotic eye with

an inability to close the eyelids

− check for periocular and eyelid lacerations.

2. Check pupillary reactions for:

− direct and consensual pupil reaction

− RAPD and pupil size

This is the most important source of information in

obtunded patients (remember that the room must

be temporarily darkened to assess this).

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Paediatric assessment

Paediatric assessment can be very difcult,

particularly if the child is injured or distressed. Do

not delegate the task of assessing a child to a junior

or an inexperienced member of the ED team and do

not separate the child from their parent(s) during

the assessment.

History

• Find out the child’s age, vaccination and

fasting status.

• Obtain a detailed history from an adult witness.

• A lot of information can be gathered by simply

observing the child while you take their history.

• Assess visual acuity for each eye based on the

patient’s age and ability to interact. Although

this can be difcult, it is vitally important and

cannot be deferred. Enlist the parent’s help for

an explanation, covering an eye or holding a

visual target. Check visual acuity before the

child becomes distressed, as may happen when

you examine them.

• Check visual acuity as appropriate for each

age group.

Babies

Assess the ability to x and follow light and

blink in response to bright lights (use a target

with a central, steady and maintained gaze). A

small child will x and reach for a bright object.

Toddlers

Assess the ability to identify and reach for a

small coloured target (e.g. single 100s and

1,000s sprinkles or similarly sized rolled up

piece of paper). Sprinkles (e.g. 100s and

1,000s) are commonly used to test ne vision

in children.

Infants

Assess visual acuity using a shape (or Snellen)

chart using a matching board (‘tumbling-E’s).

Age 5 or older

Assess using Snellen acuity test. Check pupils

and for an RAPD.

Some eyedrops will sting upon instillation.

Topical anaesthetic, although initially painful,

can be very useful as it will relieve pain for

about 20 minutes and may allow the child to

spontaneously open their eye after a

few minutes.

It may be necessary to gently restrain a child

to facilitate examination, or it may be feasible

to sedate the child in the ED, provided staff

with the appropriate training are available. In

some cases, it is necessary to plan an

examination under anaesthesia to complete

the assessment.

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Notes

If a history is unavailable, always suspect an

injury or foreign body as a cause for a red or

painful eye in a child. If you suspect non-

accidental injury (NAI), contact the relevant

child protection service in your area.

Periorbital cellulitis can be more aggressive in

children than in adults. It is normally treated by

admitting the child and placing them on

intravenous antibiotics under ophthalmology

and paediatric care.

Conjunctivitis in any child within one month of

birth is a medical emergency and requires input

from ophthalmology, infectious diseases and

potentially the child protection unit.

As is true for adult patients, do not put any

pressure on an eye that you suspect may be

ruptured. This is particularly an issue in children

where examination can be difcult. If you

suspect a globe rupture, put a shield on the eye,

fast the child and contact ophthalmology.

Orbital oor fractures in children are more

likely to adopt a greenstick conguration and

entrap part of the inferior rectus without

signicant external signs of injury. Be wary of

the classic presentation of the white-eye

blow-out fracture – a child presenting following

blunt periocular injury with an uninamed white

eye and inability to look up. They may be quite

unwell if they have a concurrent oculocardiac

reex (which is more common in children) and

this can provoke nausea, vomiting and

fatal bradyarrhythmias.

A child presenting at any age with no red reex

is said to have leukocoria. This may be noticed

by the parents, following a photograph that has

been taken, or by an optometrist. Several very

serious pathologies must be excluded in this

situation, chiey retinoblastoma. Leukocoria

requires urgent ophthalmic assessment.

As discussed in the visual acuity section,

amblyopia is a common cause of reduced vision

in adulthood. It occurs due to some sort of

visual impairment in children and cannot be

treated beyond approximately 10 years of age.

Ifyou discover unequal vision in a child whose

vision you have checked, the child may have

amblyopia that is still amenable to treatment.

Contact ophthalmology to arrange an

examination within 1–2 weeks.

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Examinations

Examination essentials

Assessment of ophthalmology patients follows the same basic pattern of history and examination as in every

other area of medicine.

Below is a brief checklist for history and examination that should be used when assessing patients with

ophthalmic complaints. Please refer to it before contacting an ophthalmologist to ensure you have addressed

all the major points. The subsequent sections provide more information on each specic area.

Key points

Consider the following in examining patients:

• Take a history, check visual acuity, perform a

general inspection at arm’s length and look for

an RAPD for all patients.

• Selected other examinations may

be appropriate.

• It is usually not necessary to dilate pupils in ED.

Only dilate a patient’s pupils after you have

spoken with an ophthalmologist (and in cases of

trauma, the neurosurgery team).

History

• Age

• Basic demographics

• Medical history

Reasons for presentation

• Visual loss

• Diplopia (double vision)

• Painful or red eyes

• Trauma or foreign body

• Flashes and oaters

• Glasses/contact lenses/eye drops

• Prior or recent eye surgery/laser/injections

Examination

Essential

1. Visual acuity

− Without and with a pinhole for each eye

− 6/5 to 6/60, counting ngers (CF), hand

movements (HM), perception of light (PL)

orno perception of light (NPL)

Figure 3.

Snellen chart

using 6m eye

chart (visual

acuity ratio

inred).

6/60

6/36

6/24

6/18

6/12

6/9

6/6

6/5

6/4

2. General inspection

− Periocular injuries or injury to the globe

− Eye red or white

− Ptosis, proptosis or obvious misalignment

of the eye

− Gross surface anatomy of the orbit, lids,

lashes and eye

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3. Pupils

− RAPD

− Direct and consensual response for each eye

− Size, shape and reactivity to light

4. Red reex with a direct ophthalmoscope

Essential in patients with visual loss or change or

neurological complaints

5. Visual elds

6. Eye movements

7. Cranial nerve examination

Additional

8. Slit lamp examination

9. Examination with direct ophthalmoscope

Contact an ophthalmologist immediately

after your assessment if you suspect

these conditions:

• Giant cell arteritis (GCA)

• Endophthalmitis

• Penetrating eye injury

• Retrobulbar haemorrhage

• Severe chemical injury

• Ophthalmia neonatorum

• Acute angle closure glaucoma

• Pain, redness or decreased vision in an

eye after any intraocular procedure

(surgery or injection) or in a contact

lens wearer

• Ophthalmic symptoms in any patient

withonly one eye (includes prosthetic

eye or long-standing poor vision in the

other eye)

Until proven otherwise

• Flashes and oaters = retinal tear

• Visual loss, visual change and diplopia in a

patient >50 years of age = GCA

• Serious periocular trauma = ruptured or

penetrated globe

• Serious periocular trauma = associated

intracranial injury

• Periocular lacerations contain a foreign body

• Eyelid lacerations are full thickness and involve

the globe

Reasons to defer visual acuity testing

• Chemical injury

• Obtunded, intubated or unconscious patient

• Severe life-threatening injury or

neurological concern

Diagnoses of exclusion

• Poor vision due to amblyopia

• Poor vision due to prior visual loss that has only

just become apparent to the patient

Reasons not to dilate a pupil

• Will not allow subsequent assessment for

an RAPD

• May precipitate angle closure

• Situations of head injury (will obviate pupil

measurements if the patient needs

neurological observations)

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General inspection and assessment

of periocular and globe trauma

A general inspection provides a wealth of

information on all patients, particularly after trauma.

Most external eye ndings can be seen with a bright

pen torch or direct ophthalmoscope. Examine the

eye in an orderly fashion, i.e. lids, conjunctiva,

cornea, iris, pupil, anterior chamber, lens.

Address the following questions:

• Is the eye red or white?

• Is the globe ruptured or penetrated?

• Are there signs of

retrobulbar haemorrhage?

• Are there periocular lacerations

and ecchymoses?

• Are there signs of cranial nerve palsy?

• Is there cellulitis or swelling of the eyelids

or skin around the eye?

• Is there a foreign body in the lids, eye

or orbit?

Remember that in all serious trauma to the eye, a

penetrating eye injury and concurrent intracranial

injury must be excluded.

1. Is the globe intact?

Always begin with observation (see

questions above) and check visual acuity,

eye movements and pupils.

If you suspect globe rupture or penetrating

eye injury, examine with the utmost care.

Do not put any pressure on the eye. Gently

distract the eyelids by pressing ONLY on

the orbital margins.

External clues:

• Missile protruding from the eye: do not

remove it or touch it

• Swollen, haemorrhagic eyelids

• Obvious prolapse of uveal contents

• Distortion of the cornea or the globe

• Circumferential conjunctival swelling

and haemorrhage

• Complete ‘8-ball’ hyphaema

If you conrm globe rupture, do not

examine any further. Put a clear plastic

shield (or other makeshift mechanical

protection) over the eye, avoiding pads or

anything that might come in contact with

the eye. Contact ophthalmologist. Any

pressure put on the eye will exacerbate

the injury.

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2. Is there a retrobulbar

haemorrhage?

External clues:

• Bulging, tense or proptotic eye with an

inability to close the eyelids following

blunt trauma

Check visual acuity and for an RAPD. The

presence of a periorbital fracture does

NOTpreclude a retrobulbar haemorrhage.

Retrobulbar haemorrhage is a clinical

diagnosis and does not need imaging for

conrmation. If you suspect it is present,

liaise urgently with an ophthalmologist,

emergency physician or a plastic or

maxillofacial surgeon to perform

canthotomy and lower lid cantholysis.

3. Are there periocular ecchymoses

(‘black eye’) and inammation?

External clues:

• Document presence and extent

Take note of any localised eyelid swellings which

may indicate abscesses or chalazia.

Bilateral periocular ecchymoses in a head trauma

patient is suggestive of a base of skull fracture.

4. Are there periocular and

eyelid lacerations?

External clues:

• Document number, size, location and depth

• All periocular lacerations must be assumed to

have a foreign body until proven otherwise

For eyelid lacerations, document which eyelid and

location (medial, middle or lateral third). Eyelid

lacerations must be assumed to be full-thickness,

(i.e. through-and-through) until proven otherwise.

Severe eyelid lacerations may result in the

inability to close the eye and protect the

ocular surface. In such situations blinding

corneal exposure can rapidly occur.

Notes

• Lacerations involving the eyelid margin

need specialised repair.

• Lacerations involving the medial-most

portion of the eyelid may also involve the

lacrimal canaliculus and need

specialised repair.

• Periorbital cellulitis may complicate

lacerations, in this case, document the

extent of erythema.

5. Documentation

For external clues, draw a diagram and provide

accurate measurements at the initial assessment.

Note whether any lacerations have been sutured

prior to your assessment. Facial scarring can be

very disguring and patients may not be aware that

scarring will result, so it is important to explain this

and document that you have had this discussion.

In accordance with NSW Health policy, in

emergency situations a personal device can be

used to capture and store relevant clinical images

due to the urgent need for care, treatment or

advice. Images should be transferred to the local

health records management system as soon as

practical and the image permanently deleted from

the personal device.

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6. Imaging

Imaging is very important following periocular

trauma for the diagnosis of periorbital fractures

and to dene globe and soft tissue injuries.

Computed tomography (CT) imaging is often the

preferred modality in orbital pathology.

If a periorbital fracture is present with

entrapment of extraocular muscles, be

alert to the possibility of the oculocardiac

reex which can cause

life-threatening bradyarrhythmias.

In all serious periocular trauma, consider

that the patient may also have intracranial

trauma. Examine, image and liaise with

other specialties accordingly.

Figure 4. Orbital oor fracture.

7. Cranial nerve palsies

Consider the following:

• Perform a cranial nerve exam as you

would normally.

• See the relevant sections for specic

assessment of pupils, visual eld (for second

cranial nerve/optic nerve) and ocular movements

for third (3rd) and sixth (6th) cranial nerves.

• Signs of a 3rd cranial nerve palsy include ptosis

on one side, an eye that is misaligned downward

and laterally, and a dilated pupil.

• Signs of a unilateral or bilateral 6th cranial

nerve palsy include misalignment of the eye(s)

medially, in addition to the inability to abduct

the eye(s).

• Signs of a seventh (7th) cranial nerve palsy

include the inability to close the eye and

drooping of the lower eyelid and corner of

the mouth.

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Visual acuity

Visual acuity provides the most important

information about how an eye is functioning and is

the basic means of examining an ophthalmology

patient. It is analogous to blood pressure

measurement or an electrocardiogram (ECG).

Visual acuity must be checked in any patient with

an ophthalmic complaint or periocular injury.

Visual acuity assessment is not complete

unless the following are performed:

• Checked in each eye separately

• With the patient’s distance correction

(distance glasses)

• Without then with a pinhole

• Documented in notes

Technique

Visual acuity assessment can be confusing, so

keep it simple.

1. Sit the patient 6m away from the chart or 3m

away from a mirror that is reecting a chart

positioned above their head, thus creating an

optical 6m. Make sure that the chart is

illuminated (either room lights are on, or the

globe is turned on behind the chart if it is a

retro-illuminated chart).

2. Ask the patient to put on their distance glasses

(the glasses they use for driving, not reading). If

you are unsure, try with and without; distance

glasses will improve the patient’s

distance vision.

3. Use a solid object to occlude one eye. If the

patient is using their hand, ask them to hold the

palm of their hand gently up against their eye,

rather than their ngers, as it is possible to

peek through ngers.

Options to ensure the eye is fully occluded:

Figure 5. Correct.

Figure 6. Correct.

Figure 7. Correct.

Figure 8. Incorrect: beware of peeking!

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4. Ask the patient to read as low down on the chart

as they can. Don’t correct the patient if they

make a mistake. Provide encouragement

irrespective of whether they are correct or

incorrect. Don’t let the patient give up once

things become blurry, instead encourage them

to keep going. It is not uncommon for patients

to give up several lines above their actual acuity

because it is blurry. Push them to get as low as

possible on the chart. A patient’s visual acuity is

dened as the line where they correctly guess

≥50% of the letters, whether they appear blurry

or not.

5. Document as you go, using the following

convention: the number ‘6’ over the number of

the lowest line that the patient can read (that is,

60, 36, 24, 18, 12, 9, 6, 5), giving you the familiar

fraction (6/60, 6/36, 6/24, 6/18, 6/12, 6/9, 6/6,

6/5). ‘RVA with glasses + pinhole is 6/18’ is

equivalent to saying that your patient, with

distance glasses and a superimposed pinhole,

can see at 6m what a normal person can see at

18m (6/18, which is a fraction less than 1, can be

thought of as less than normal vision). The top

number refers to the testing distance, (e.g. 6)

and the bottom number refers to the size of the

letters the patient sees (e.g. 6, 9, 12, 18, 24, 60).

6. Now test the eye looking through a pinhole. Use

an occluder with a pinhole, or, if not available,

poke a hole in a piece of paper with a 19G

needle (or even the tip of a pen). Look through it

yourself before giving it to the patient to ensure

that the aperture is clear. You may be surprised

to note that your vision improves as well. Do

NOT attempt to make a pinhole while the

patient is holding the paper over their eye. Ask

the patient to read the chart again and record

the pinhole acuity as above.

7. If the patient cannot read the largest line on the

chart, test if they can count how many ngers

you are holding up in front of their eye. Test

progressively at 30cm, 1m, 2m and 3m. If

Figure 9. Pinhole occluder.

possible, record vision as CF and the distance at

which you measured.

8. If the patient cannot count ngers, assess

whether that eye can see your hand moving.

Wave your hand back and forth in front of their

eye at 30cm or more. If you are too close, they

may perceive light ickering, feel the air

movement on their face or hear your bracelets,

rather than see your hand moving. Ask the

patient to either describe the direction your

hand is moving or mirror the movement with

their hand. If possible, record vision as HM.

9. If the patient cannot perceive hand movements,

darken the room lights, ensure the other eye is

completely occluded and shine a bright light

into the eye from about 10cm. Ask if they can

see it. Shine the light on and off the eye

repeatedly and ask the patient to identify when

the light is on their eye. If they can, vision can be

recorded as light perception (LP or PL). If they

cannot, it is recorded as no light perception

(NLP or NPL).

10. Repeat the same process with the other eye.

Video - How to measure visual acuity

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Notes

Visual acuity must be checked for every patient

with an ophthalmic complaint or periocular

injury. It is of vital importance for assessment

and prognosis. There are instances in which

visual acuity assessment can be deferred, e.g.

acute chemical injury, where irrigation takes

priority, or in severe life-threatening trauma

where attending to life-threatening injuries

takes priority. However, in both cases, visual

acuity must still be assessed at some stage to

ensure severe eye injuries are not missed.

Visual acuity must be documented in your

notes. Avoid writing ‘normal visual acuity’ or

‘blind’ as this does not provide any objective

information. Instead, record the specic acuity

in each eye without, then with, a pinhole. If this

is omitted, or the specic acuity is not

documented, the statement ‘normal visual

acuity’ can subsequently be challenged. This is

particularly an issue during handover in EDs,

where a colleague may have claimed to check

visual acuity but not recorded it.

It is unacceptable to say that a patient has

‘normal’ or ‘6/6’ vision because they can read

newspaper print, the writing on an IV bag, the

lowest line on a handheld chart or anything

other than the 6/6 line on a Snellen chart that is

6m away. Similarly, documenting vision as

counting ngers because that is all you have

checked and you do not have an acuity chart

means that the patient’s vision has not been

examined. It may be tempting to do these things

because measuring visual acuity using a chart

can be inconvenient, but it means visual acuity

has not been correctly checked, and there can

potentially be serious medical and

medicolegal repercussions.

A vision of 6/6 does not preclude serious

ocular pathology.

Test the eye that you suspect to have poorer

vision rst, to lessen the chance that the patient

will remember the letters when you test the

other eye. Observe the patient carefully during

the test to ensure that they are not looking

around the occluder or their hand or peeking in

another way. Visual acuity testing is an

objective test and the patient can either read

the letters or not, irrespective of whether they

are subjectively blurry or clear.

A patient must get at least 50% of the letters

correct on each line to be credited with that

acuity. It is possible to record mistaken letters

(on a line that was achieved) with a superscript

of -1, -2 or -3, or extra correct letters on the next

line (if the whole line was not achieved) with a

superscript of +1, +2 or +3 next to the visual

acuity. For example, you may record the acuity

as 6/12-1.

Patients may not know which glasses you mean

when you ask them to put on their ‘distance

glasses’. You can be more specic by asking

which glasses they use to drive or watch TV. If

there is still confusion, simply test the vision

with and without each pair. Multifocal glasses

provide distance correction when looking

through the top segment and near correction

when looking through the lower segment.

Ensure that the occluder used for the other eye

is not pushing multifocal glasses up the

patient’s nose, causing them to look through

the glasses’ reading segment.

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A pinhole works by eliminating spherical

aberration, or the poorly focused rays of light

that are refracted at the periphery of a lens (in

this case, the eye’s tear lm, cornea and lens). A

pinhole eliminates most refractive error and

approximates a ‘universal’ lens, and this gives

vital information about an eye’s best possible

vision. Visual acuity testing is not complete until

pinhole acuity for each eye is tested and

recorded. Remember that visual acuity testing

should be done with glasses and then with a

pinhole as well. It is a common misconception

that testing with glasses and with a pinhole are

mutually exclusive. If a patient’s distance

glasses have not been updated for some time,

they may have signicantly better acuity when

tested with a pinhole as well.

‘Normal’ visual acuity or 6/6 means that the

patient can see at 6m the same target that a

person with normal vision can see at 6m. As the

denominator increases, the visual acuity

decreases, so a vision of 6/60 means that while

a person with normal vision could see the target

at 60m, the patient can only see it at 6m.

Similarly, 6/36 vision means that while a person

with normal vision could see the target at 36m,

the patient can only see it at 6m.

The distance to the chart is of paramount

importance. If the chart is closer, it will give an

inaccurate visual acuity. While it is possible to

mathematically adjust the ratio to reect a

shorter viewing distance, this adds an

unnecessary level of complexity to an ED

assessment. Keep it simple and check at 6m

(either directly or reected in a mirror).

Near acuity (or reading vision) as checked with a

handheld chart or a mobile phone app is an

alternate means of checking acuity but is NOT

readily interchangeable with distance acuity.

Snellen distance acuity is the standard method

of measuring a patient’s acuity and has the

most clinical relevance. It can create confusion

if a different method is used, particularly when

the acuity on presentation in ED is needed for

comparison at later stages in the

patient’s assessment.

An alternative to using a wall-mounted chart is

a scaled, handheld paper chart that is held at

3m. This is particularly useful for examining

bed-bound or recumbent patients. However, it is

more prone to inaccuracy as it is difcult to

calibrate exactly 3m from the patient’s eye and

charts that have been photocopied suffer a

degradation in contrast which can also

articially degrade visual acuity. Many of these

charts are also inaccurately labelled

concerning the visual acuity corresponding to

each line.

Patients who do not recognise the common

Snellen letters can be tested with the

‘tumbling-E’ chart. This replaces Snellen letters

with the letter ‘E’ in four different orientations:

up, down, left or right. The patient is asked to

point in the direction that the ‘E’ is pointing on

the chart.

If a patient is in pain, it is reasonable to instil a

drop of local anaesthetic to facilitate checking

visual acuity. Give the patient a few minutes

after anaesthetic instillation for the eyelid

spasm to subside.

Although amblyopia is a common cause of

unilateral poor vision in adults, do not attribute

reduced vision in ED to amblyopia. It is a

diagnosis of exclusion. Amblyopic eyes are as

prone to pathology as non-amblyopic eyes, and,

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in some cases, more likely to be injured. Be

especially attentive if a patient describes

further worsening of vision in an eye that

was suspected to be amblyopic.

A vision of NLP has an extremely poor

prognosis and tends only to occur in the

very end stage of diseases such as

glaucoma, retinal detachment, injury to the

optic nerve or following serious injury. While

you may encounter patients in whom an eye

has been NLP for some years, if an eye

suddenly becomes NLP, then very serious

pathology is present. In patients over 50

years old, abrupt loss of vision to NLP

means GCA until proven otherwise. Liaise

with an ophthalmologist and commence

treatment to prevent a similar occurrence in

the other eye.

Common pathologies such as

cataracts, vitreous haemorrhage

and amblyopia do not cause vision

of NLP. The instances in which an

eye recovers some vision after

having been NLP are very rare.

Pupil examination

Pupil examination is a vital part of both the

ophthalmic and neurological assessment. It must

be done in all patients. In obtunded or severely

injured patients it may be the only type of

examination possible other than general inspection

and fundoscopy.

Pupil examination is not complete unless you have

assessed for an RAPD.

If a pupil abnormality is detected, you must also

examine the patient’s eye movements, eyelids and

visual eld.

Key aspects of pupil examination are size, shape

and reactivity. In ambient light, both pupils should

be of equal size and shape. Physiological anisocoria

is present in up to 15% of the population and does

not imply an RAPD.

Technique

Pupil examination technique requires the following:

1. Observe pupil size in the light. Ask the patient

to look at a target behind you, so that there is no

accommodation on a near target which will

inuence the size of the pupils. Look for a

difference in pupil size (anisocoria), difference

in iris colour (heterochromia) or irregularity of

the normally round shape.

2. Darken the room and check pupil size again.

Note whether any difference in pupil size is

more pronounced in the light or the dark.

3. Shine a bright light into one pupil and observe it

constricting to assess the direct pupil response

on that side.

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4. Check that the other eye also constricts to

assess the consensual light reex. Repeat this

process by shining the light into the other eye.

5. Check for an RAPD. Shine a bright light into one

pupil for 2–3 seconds, then rapidly ick the

light across to the other side, and hold it for the

same duration. An RAPD is present if the pupil

initially dilates (instead of initially constricting)

when icking across from the other side. You

can go back and forth several times until

convinced of the ndings, provided that the

time over each eye is the same and the time in

between the eyes is very short.

Video - How to examine an RAPD

Notes

Although an RAPD may be subtle in some

cases, it is a vitally important clinical sign to

elicit in situations of sudden visual loss and

ophthalmic trauma.

When pupils have been pharmacologically

dilated, it is not possible to test for an RAPD.

This is one of the principal reasons that

pupils are not dilated in ED prior to

ophthalmic assessment.

The key to detecting an RAPD reliably is to

ensure that each eye is exposed to the same

amount of bright light for the same amount of

time, with the briefest possible transit

between each eye. It is possible to mistakenly

give the impression of an RAPD if the light

intensity or the time over each eye varies.

The principle behind an RAPD is that by

alternately presenting each eye with a

symmetrical, intense light source, a subtle

unilateral optic nerve defect will be exposed.

If the optic nerve is damaged on one side,

when the light icks to that eye, the direct

response is less than the consensual

response from the recent contralateral light

stimulation, and so the pupil is observed to

dilate. It should be noted that this

observation is based on the direct and

consensual pupillary reexes being equal

in amplitude.

Vision loss in giant cell arteritis (GCA)

(or any other cause of optic neuropathy)

is associated with a relative afferent

pupillary defect (RAPD).

It may be hard to assess pupil size in the dark

if the patient has a dark-coloured iris.

Experiment with using a diffuse light shone

from above or below that allows you to see

the pupil without inuencing its size or with a

single-ash camera.

Remember that a unilaterally dilated

pupil on one side may indicate an

acute third (3rd) cranial nerve palsy

and urgent neuroimaging and liaison

with a neurosurgical service is

required if detected.

There are many situations in which pupils

may be abnormally shaped, including

intraocular inammation, prior surgery or

accidental trauma.

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Swinging torch test

This involves demonstrating a left relative afferent

pupillary defect where the left pupil dilates after

prior consensual constriction with direct light

stimulation of the right eye.

Figure 10. Swinging torch test

(consensual constriction).

Figure 11. Swinging torch test (left pupil

apparent dilation).

Visual eld, eye movements

andeyelid examination

Visual eld, eye movement testing and eyelid

examination are not mandatory in all ophthalmic

patients (for example, a simple foreign body) but

must be tested in anyone with visual changes or

suspected optic nerve, orbital or neurological

pathology. If a patient has a pupil abnormality,

these three examinations must be performed.

Given how rapidly and easily it can be done, have a

low threshold for testing it if you think it might

be relevant.

Technique for visual eld

Video - Technique for visual eld

1. Begin by explaining what you are going to do.

Telling the patient that you are testing their

‘peripheral vision’ can make it easier for the

patient to follow your instructions.

2. Ask the patient to remove their glasses so that

the rims do notinterfere with the assessment.

3. Sit opposite the patient with your eyes at the

same height, about 50cm away from their face.

4. Place a hand over one of your eyes and ask the

patient to mirror you, e.g. if you cover your left

eye, they cover their right eye.

5. Ask the patient to keep their eye covered, to

look directly at your eye with their uncovered

eye, and not to look away.

6. Clench the st of your free hand and hold it in a

reasonably peripheral position in one quadrant

of your peripheral vision.

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7. Ask the patient how many ngers they see

and hold up a random number. Look at the

patient’s eye to ensure that they do not look at

your hand.

8. Test in all four quadrants in the same manner

and repeat the process on the other side.

9. Test for a scotoma by slowly moving your

nger from an area where the patient cannot

see to where they can. Repeat until you have

mapped the scotoma to your satisfaction.

Notes

Visual eld testing to confrontation is

unlikely to allow you to detect subtle or

small visual eld defects but larger defects

can be detected.

As you are sitting opposite the patient, your

visual eld is a reasonable approximation of

theirs. It is important to hold your hands in

the same coronal plane in each position and

equidistant from you and the patient.

Neglecting to do this distorts the eld that

you are assessing.

You can use the hand that was covering your

eye, provided you keep that eye closed and

remember the position of that monocular

visual eld with your hand in place. This

makes the examination more uid.

Alternatively, you can switch hands.

You can hold up several nger combinations

in each quadrant to ensure that the patient

can see them.

It is not uncommon for patients to

inadvertently look at your hand when they

realise your ngers are moving. The most

important thing is to recognise when this

happens, remind the patient to look at your

eye instead and repeat the step with a

different number of ngers.

A patient’s visual acuity must be at least

counting ngers to allow you to test their

eld to confrontation.

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Technique for eye movements

Eye movement examination must be performed

in any patient with diplopia (double vision), pupil

or eyelid abnormalities.

Eye movement examination technique requires

the following:

1. Explain what you are going to do by asking

the patient to keep their head still and follow

your nger with their eyes.

2. Hold your index nger up in front of the

patient, then trace an ‘H’ pattern in a coronal

plane in front of them.

3. Ask the patient to tell you if they have double

vision, (e.g. ‘see two ngers’) in any position

of the ‘H’.

4. Following this, assess each eye separately by

asking the patient to cover one eye and

testing the movements of the other side.

5. Switch over so that both eyes are assessed in

this way. If the patient is experiencing

binocular diplopia, they will not experience

diplopia when one eye is covered.

Notes

When testing eye movements, it may help to

gently place a nger on the patient’s chin or

forehead to remind them not to follow with

their head.

If a patient has an eye movement disorder

you must check their pupils, eyelid and

visual eld.

In a sixth (6th) cranial nerve palsy, the

patient may not be able to abduct their eye.

In a third (3rd) cranial nerve palsy, the

patient may not be able to elevate, depress

or adduct the eye, and you may notice

associated pupil and eyelid changes.

In an orbital wall fracture, the patient may

not be able to move the eye in the opposite

direction, especially if there is associated

entrapment of the extraocular muscles

(e.g. inability to elevate the eye in an orbital

oor fracture).

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Eyelid examination

Eyelid examination must be performed in any

patient with diplopia (double vision), pupil

abnormalities or eye movement disorder and

requires the following:

• Observe for ptosis (drooping of the upper

eyelid over the eye, which may be unilateral or

bilateral). Compare the position of the upper

eyelid on one side with the other. This can be

done by simply judging the relation of the

upper eyelid to the top of the pupil or more

accurately by measuring the vertical height of

the palpebral aperture with a ruler.

• Ask the patient to close their eyes. Determine

whether there is any weakness in this action by

rst observing and then gently trying to part

the eyelids.

Notes

Opening the eye relies upon the third

(oculomotor) cranial nerve and the

sympathetic bres. Therefore, a lesion of the

oculomotor nerve causes ptosis, and if severe

enough, inability to open the eye. A lesion of

the sympathetic bres causes Horner

syndrome and less ptosis.

Other causes of ptosis include trauma,

swelling of the upper eyelid or age-related

degeneration of eyelid tissue.

Closing the eye relies upon the seventh (7th or

facial) cranial nerve. Lesion of the facial nerve

can result in an inability to close the eye, in

addition to drooping of the lower eyelid and

the corner of the mouth. Testing for eyelid

closure in this manner is the same manoeuvre

used in checking facial nerve function.

Inability to close the eye is called

lagophthalmos and, if severe, can

lead rapidly (within hours) to corneal

exposure, irreversible scarring

and blindness.

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Eyelid eversion

Eyelids must be everted to exclude a subtarsal

foreign body.

Technique

1. Ask the patient to look down.

2. Gently pull the upper eyelid down and away

from the globe using the eyelashes.

3. Place a cotton bud at the midpoint on top of

the eyelid, then bend the eyelid up over the

cotton bud.

4. Slide the cotton bud out and either replace it

on the lid margin to hold the lid in position or

use your nger to do so.

Video - Eyelid eversion

Notes

It is most efcient to evert an eyelid at the

slit lamp, as your view of any potential

subtarsal foreign bodies will be better.

These may be gently removed with a moist

cotton bud.

Patients are often quite averse to having

their eyelids everted. Explain what you are

going to do, and that while it may feel

unusual, it should not be uncomfortable.

It may be easier to grip the edge of the

eyelid and eyelashes if you wear a glove.

Figure 12. Everting eyelid.

Figure 13. Everting eyelid.

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Special eye examinations

Direct ophthalmoscope

It is not necessary to perform a detailed

examination with a direct ophthalmoscope for an

ED ophthalmology assessment, although it is very

helpful if you use it to determine whether the

patient has a red reex or not. Examination with a

direct ophthalmoscope does not take priority over

the simple assessment of visual acuity, pupils and

general inspection.

Do not dilate a patient’s pupils until you have

spoken with an ophthalmologist as it means that an

RAPD cannot be assessed and the patient cannot

have pupil observations for several hours.

Technique

Video -

Direct ophthalmoscope examination

1. Watch the video of direct

ophthalmoscope examination.

2. Darken the room and ask the patient to look at a

target behind you on the wall.

3. Adjust the dioptric correction to zero. Turn the

ophthalmoscope light on.

4. Use the same eye as the one you are examining

on the patient, i.e. your right eye for the

patient’s right eye.

5. Standing back from the patient, look through

the viewing aperture and shine the light into the

patient’s pupil. You should see a red reection

(‘red reex’).

6. If necessary, adjust the dioptric correction to

improve the clarity of the image.

7. To examine the retina, move in closer, keeping

the light focused on the red reex. You must get

very close to the patient (within 5cm).

8. When you are close enough you will see some

retinal detail, usually a retinal blood vessel.

Follow this vessel until you can see the

optic disc.

Notes

The direct ophthalmoscope provides a

highly magnied, narrow angle view of the

fundus. It cannot reliably be used to

examine the retina in sufcient detail to

exclude pathology. For this reason, patients

with suspected posterior segment

pathology such as optic disc swelling or

retinal tears need to be examined by

an ophthalmologist.

Other tools may be available in your ED also,

including a pan ophthalmoscope or a

non-mydriatic fundus camera. Acquiring one

of these is highly recommended.

Loss of the red reex occurs in several

conditions (such as retinoblastoma,

cataract, vitreous haemorrhage or retinal

detachment) and this information can assist

greatly with triaging ophthalmic referrals.

It is much easier to examine the retina if the

patient’s pupil is pharmacologically dilated.

However, pupil dilation prevents subsequent

assessment for an RAPD, can rarely

precipitate acute angle closure in some

patients and obscures neurological

observations in patients with a head injury.

For these reasons, pupil dilation should only

be undertaken after discussion with an

ophthalmologist (and, in some cases,

a neurosurgeon).

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Checking intraocular pressure

Although not available in every ED, several

handheld devices can be used to measure

intraocular pressure.

Never check intraocular pressure if you suspect

that a globe may be ruptured.

Applanation tonometers (e.g. Tono-pen)

Video - Tono-pen technique

1. Explain what you are going to do to the patient.

Position the patient upright, looking in a

horizontal direction.

2. Administer topical anaesthetic (tetracaine or

plain lignocaine).

3. Place a disposable rubber shield over the

tonometer probe. Use a different shield for

each patient.

4. Turn the tonometer on using the button on the

top of the device. Wait for it to beep and for the

display to come on.

5. Holding the tonometer horizontally, gently tap

the probe against the centre of the cornea

several times. You may need to gently hold the

patient’s eyelids open to achieve this.

6. The tonometer will make ten recordings in quick

succession and then beep loudly, displaying the

average intraocular pressure on the screen.

Notes

Patients can be quite anxious about having

their pressures checked, as many have

unpleasant recollections of the ‘puff’

tonometers that are commonly used by

optometrists. You can reassure the patient

that this is a different technique and that

while it may feel unusual, it will not be

uncomfortable (apart from the

topical anaesthetic).

If holding the patient’s eyelids with your

ngers, make sure you are not pressing on

the globe itself as this will cause an

inaccurately high pressure reading. Restrain

the eyelids by tethering them to the bony

orbital margins.

Always store the tonometer with a cardboard

sleeve over the probe, as this part of the

device can be very easily damaged.

As with any test, it is possible to get

erroneous measurements. If you doubt the

reading, repeat the examination.

Troubleshooting tips are to ensure the sleeve

is taut across the tip of the device, and that

measurements are taken from the central

cornea, holding the tonometer in a horizontal

position. If you are having difculty getting

ten readings (which should be very rapid),

make sure that the tonometer is in contact

with the cornea and make very small to-and-

fro movements with your hand.

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Rebound tonometer (e.g. iCare)

Video - iCare tonometer technique

1. Tell the patient what you are going to do.

2. Turn the device on. It will prompt you to insert a

small, disposable, round-ended pin-like probe.

Once inserted, the probe will shudder back-

and-forth for a moment as the device conrms

its position.

3. Hold the device vertically just in front of the

eye. The probe should be horizontal, only a few

millimetres away from the eye and pointing at

the central cornea.

4. Press the button. The probe will gently rebound

off the cornea and then return to position,

usually quicker than the patient can blink.

5. Press four more times. The machine will collect

ve readings and then display the

intraocular pressure.

Notes

Explain to the patient that this device is

different to the puff tonometry they may

have experienced before and that this will

not cause any discomfort.

Unlike applanation tonometers, you do

not need topical anaesthetic to check the

intraocular pressure with a rebound tonometer.

The patient may feel the contact with their

cornea, but the sensation is remarkably light

and, in some cases is only barely noticed.

Because rebound tonometers are so fast, you

often do not need to hold the patient’s

eyelids. However, the rapid succession of

beeps and barely appreciated sensations on

the cornea can be bewildering. It often helps

to pick your moment and time each

measurement between blinks. Speaking

calmly to the patient and reassuring them is

very important.

A rebound tonometer may be superior for

checking intraocular pressure in children

because it is so rapid and does not need

topical anaesthetic or pressure on the eyelids.

Some rebound tonometers can be held at

orientations other than vertical, making

them more useful for recumbent and

bed-bound patients.

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Slit lamp

A slit lamp is a binocular microscope with an

adjustable, confocal light source that enables the

ophthalmologist to examine the eye in detail, from

the eyelids to the retina. Although a slit lamp

examination is often not wholly necessary for the

basic assessment of an ophthalmology patient, it is

certainly preferable and remains vital for such

conditions as corneal foreign bodies and corneal

epithelial defects.

Technique (e.g. Haag-Streit slit lamps)

Video - How to use a slit lamp in 5 minutes

Video - Slit lamp basic examination

1. Ensure that both you and the patient are sitting

on height-adjustable chairs. Bring both chairs

close to the slit lamp.

2. Adjust the table height so that the patient can

place their chin on the chin rest and their

forehead can touch the headrest.

3. Adjust the height of the chin rest so that the

patient’s lateral canthus is aligned with the

black grooved line on the vertical support.

4. Adjust the eyepieces so that they are both at

‘zero’. If you have a refractive error, it is best to

wear your own spectacles. While it is possible to

adjust the optics of the slit lamp to compensate,

this can create unnecessary confusion.

5. Turn the lter selection switch to the left-most

(or second from left-most) position. This is the

brightest setting and will allow you to see more

of the eye. While it is bright, the patient’s

perception of brightness comes mostly from

the width of the beam.

6. Adjust the aperture height knob to create a

maximally tall beam (8mm) and the aperture

width knob to create a very narrow beam

(<0.5mm). This gives the best viewing

characteristics. A beam that is too wide will

make it harder for you to appreciate depth and

be uncomfortable for the patient.

7. Turn the illumination arm to the same side as

the eye that you are examining and angle it

between 30° and 60° from the midline. Ask the

patient to look at your opposite ear with their

other eye. Switch the arrangement when you

switch eyes.

8. Turn the slit lamp on and adjust the

characteristics of the light beam if needed.

9. Begin by coarse-focusing. Do not look through

the microscope initially, but instead look beside

it at the light shining on the patient’s face. Move

the whole slit lamp base to bring the light into

sharp focus on the patient’s eye. You can then

look through the microscope.

10. Adjust the width of the eyepieces as you would

on a pair of binoculars.

11. Fine-focus moving the joystick backwards and

forwards. There is nothing else you need to do

to focus. Experiment by moving backwards and

forwards and observing the effect it has on

what you can see. You can move the beam up

and down by turning the joystick.

12. When focused on the eye, examine the

periocular skin, lids, eyelashes, cornea, iris and

lens in an anteroposterior systematic fashion.

Note the location, size and apparent

composition of any foreign bodies.

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13. To search for a corneal epithelial defect,

administer a drop of uorescein and examine

with the cobalt blue light. This is obtained by

turning the height aperture knob beyond 8mm

until a stop with a blue dot appears. The beam

will turn blue. Widen your beam to the

maximum, as you will usually want to scan the

ocular surface for uorescein staining.

14. When nished, turn the slit lamp off and ask the

patient to sit back. Do not leave the patient

stranded or trapped behind the slit lamp or with

their feet elevated off the ground.

Notes

Patients sometimes lean back during the

examination, pulling their forehead away from

the headrest and causing the eye to go out of

focus. Check the patient’s position periodically

and remind them to come forward again if they

have drifted away. Checking head position is

essential during foreign body

removal procedures.

Ergonomics are important. Adjust the height of

your chairs and that of the table to ensure

comfort. Apart from causing injury, if the

patient is uncomfortable, they are more likely to

drift away, and if you are uncomfortable, you

are less likely to examine them thoroughly.

The cobalt blue light is obtained by turning the

height aperture knob one click beyond 8mm.

The green lter (on the lter selection switch) is

commonly mistaken for the cobalt blue light but

it has different optical characteristics. If you are

looking for an epithelial defect with a green

light, then stop, turn the lter selection switch

back to the left and adjust the height knob until

it stops at the blue light.

Use the terms ‘corneal epithelial defect’ or

‘punctate epithelial erosions’ when describing

what you see with uorescein and the cobalt

blue light. ‘Diffuse uorescein uptake’ is not a

useful descriptive term, and usually means that

the slit lamp was out of focus, that the green

light was used instead of the blue or that the

examiner put too much uorescein into the eye

and did not wait for it to disperse.

The technique for looking for cells is to darken

the room, adjust the height and width apertures

to produce a 1mm x 1mm beam, and direct it

from 45° across the patient’s pupil while

focusing on the middle of the anterior chamber.

Increase the magnication by switching the

lever beneath the eyepieces. Cells will be

illuminated against the dark backdrop of the

pupil as they traverse the light beam, like dust

particles in a sunbeam. While this is a good

thing to test for, it is not considered a standard

part of the ED assessment.

Video - Slit lamp examination

for cells and are

As mentioned above, you can adjust the

magnication by switching the lever beneath

the eyepieces. This can be useful in certain

situations, but in general, keep the slit lamp on

the lower magnication. This makes it easier to

focus and the more zoomed-out view will give

you a better appreciation of normal anatomy

and pathology.

Turn the slit lamp off when you are nished

examining and clean its surfaces

between patients.

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Troubleshooting

If there is no light when you turn the slit lamp on,

check that:

• it is plugged in and turned on at the power point

• the LED light next to the ON switch is illuminated

• the width and height apertures are open.

Notes

If the width aperture is closed no light will

appear. This is a common reason for no light to

appear. Simply widen the beam to x this.

Similarly, if the height aperture or one of the

lters is turned halfway between stops, light

may not appear. Turn all the way to a stop to

x this.

Does the bulb need to be replaced?

If these simple points are addressed and there

is still no light, this may be the case.

Emergency departments usually have spare

bulbs, but only someone who has experience

replacing a bulb should do so. Ensure that the

slit lamp is turned off and unplugged before

proceeding. If the bulb housing is screwed

down too tightly, or the bulb is not aligned

properly in the socket, it may not work until

these issues have been corrected.

If the view is blurry, try:

• wearing your own glasses

• ensuring the eyepieces are fully pushed in

and dialled to 'zero'

• going through the same process of coarse-

and then ne-focus.

The eyepieces (or oculars) can be adjusted to

account for your refractive error or induced

instrument myopia. However, it is simpler to

wear your own spectacles and keep the

oculars on ‘zero’ (align the little mark opposite

‘0’). The eyepieces can also be removed (for

cleaning) and occasionally you will encounter

slit lamps in which the oculars have been

inadvertently left partially out. Push them in to

make your view clearer.

If you are seeing clearly but not with both

eyes, try:

• adjusting the interpupillary distance by

altering the width between the eyepieces

just like a pair of binoculars

• moving the light column slightly to one side

or the other (sometimes the light column

can obstruct the view through

one eyepiece).

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Eye referrals and discharge advice

Traumacommunication

checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

Acute visual disturbance

communication checklist

Consider the following in the presenting patient:

; Presenting complaint: timing,

worsening/improving, monocular/binocular

; Past ocular/medical history

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination (anisocoria and presence

of an RAPD)

; Red reex

; Dilated retinal examination

Red eye or eyelid

communication checklist

Consider the following in the presenting patient:

; What was the onset and duration

of symptoms?

; Is the eye painful or not painful?

; What is the distribution of redness? Is it

localised or diffuse? Does it involve the

tarsal conjunctiva?

; Is the condition purely unilateral or are

there contralateral symptoms?

; What is the best (pinhole) visual acuity of

each eye?

; Are the eyelids involved? Are they red

or swollen?

; Is the cornea normal? Are cloudiness,

opacities or uorescein staining visible?

; Is the anterior chamber normal? Is it deep?

Presence of anterior chamber cells, blood

or hypopyon?

; Is the iris normal? Round, equal, reactive

pupils? Are the normal iris details visible?

; Are the red reexes equal?

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Visual requirements for driving

Be aware of driving requirements when assessing a

patient with an ophthalmic complaint. Visual

requirements differ depending on whether

someone is a private or commercial driver. A

commercial driver is anyone who drives during their

occupation other than to and from work (such as

bus, truck and taxi drivers, and most couriers) and

there are more stringent licensing requirements

than for private vehicle driving.

Private vehicle licence: visual acuity of 6/12 or

better with both eyes open or in the better eye.

Commercial vehicle licence: visual acuity of 6/9 or

better in the better eye AND 6/18 or better in the

poorer eye.

For drivers in NSW, further information is available

from Transport for NSW.

A person with only one eye (monocular) cannot hold

an unconditional private or commercial driver’s

licence. A conditional licence may be considered by

the driver licensing authority subject to 2-yearly

review, considering the nature of the driving task

and information provided by the treating

optometrist or ophthalmologist. Specic visual

standards must be met that differ for private versus

commercial drivers.

A period of adaptation is required (usually 3

months) after someone is rendered monocular

before they can resume driving. This is because it

takes time to compensate for the loss of

binocularity and peripheral eld and become

familiar with the monocular cues that can provide a

simulacrum of binocular viewing.

Patients with symptomatic diplopia (double vision)

are not permitted to drive. While wearing a patch (or

occluder) over one eye can abolish binocular

diplopia, it also renders the patient monocular and

hence the 3-month adaptation period applies.

A visual eld with both eyes open of 110°

horizontally and 20° vertically (at least 10° above

and below the horizontal midline) without any

signicant eld loss within the central 20° is

required for private driving licences. A commercial

driver is not t to hold an unconditional licence if

they have a visual eld defect. A conditional licence

may be considered if the binocular visual eld is

static, has an extent of at least 140° within 10°

above and below the horizontal midline and no

signicant eld loss is likely to impede driving

performance. A homonymous quadrantanopia or

hemianopia is considered inadequate peripheral

vision. Formal visual eld assessment (perimetry) is

done by an optometrist or ophthalmologist.

If a patient has a visual acuity or eld defect that

violates these requirements, it is your responsibility

to inform the patient that they cannot drive and

document this discussion. In some Australian

states, it is also mandatory for the doctor to

contact the licensing authority to inform them that

the patient’s licence must be suspended.

The Austroads national driver medical standards

Assessing Fitness to Drive set out the

considerations and medical criteria for safe driving.

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Prevention of visual impairment

The main causes of visual impairment in Australia

are cataracts, macular degeneration and glaucoma,

with the common main risk factor of age. With an

ageing population, the prevalence of visual

impairment is expected to rise.

Diabetic retinopathy

Diabetic retinopathy is the main cause of blindness

among the Australian working population. It is well

established that the microvascular complications

of diabetes, such as retinopathy, can be prevented

by tight glycaemic control. Health professionals

have the important responsibility of educating

patients, including promoting lifestyle changes

such as smoking cessation, exercising regularly

and maintaining a healthy, well-balanced diet.

These not only improve glycaemic control but also

lower blood pressure and reduce the risk of

developing other eye conditions such as macular

degeneration and glaucoma.

Children

Children under the age of 8 are a unique group

where any signicant ocular pathology must be

addressed during this ‘critical period’ of visual

development. Prolonged visual deprivation,

strabismus or refractive errors lead to amblyopia,

which means that the affected eye will have poorer

acuity even if the visual pathway is later optimised.

Therefore, the importance of screening children on

more than one occasion during this ‘critical period’

cannot be overemphasised.

Ocular trauma is a major preventable cause of

visual impairment, with several studies suggesting

that 90% of cases are avoidable. For reasons that

remain unclear, children are overrepresented in this

group. Education, such as the EYEPLAYSAFE

online modules, aims to increase awareness of

potential hazards in school, at home and in outdoor

environments that may lead to ocular injury.

Work injuries

In the adult population, those who work with any

form of metal, particularly using powered hand

tools, are at increased risk of penetrating eye

injuries. Globe rupture tends to occur more

frequently in the older population, with the

combination of falls and a weakened globe, (e.g.

from previous cataract surgery) placing them at

particular risk.

The mandatory use of safety eyewear in the

workplace that complies with Australian Standards

and recommends the use of protection at home

when performing do-it-yourself activities should be

reinforced. Patients who present with a supercial

foreign body should be counselled about these

risks. Furthermore, patients who have intraocular

surgery should be counselled about the risk of

globe rupture in the future, even with only minor

trauma, which usually has a very poor

visual outcome.

These statistics highlight the importance of

implementing prevention strategies to reduce the

burden of disease caused by visual impairment

within Australia, and primary care health

professionals are perhaps in the best position to

promote these.

NSW public specialist

outpatient services

This information is designed as a guide only and

does not replace clinician judgment.

Use the link below for statewide referral criteria

(SRC) for ophthalmology.

https://www.health.nsw.gov.au/outpatients/

referrals

Eye trauma

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Eye trauma

Blunt ocular trauma

Consider the following for blunt eye trauma:

• Difculty opening eyelids and a very tense

orbit suggest retrobulbar haemorrhage.

• Exclude serious head injury depending

on the mechanism of injury and consider

a brain CT.

• Previous eye surgery increases the risk

of open globe injury.

• Small projectiles at high velocities

increase the likelihood of

penetrating trauma.

Figure 14. Ruptured globe with the expulsion of

ocular tissues.

History ndings

• Mechanism of injury: if applicable, the type of

projectile and velocity should be documented

• Flashes and/or oaters: suggest retinal injury

• Double vision: suggests muscle injury or

nerve palsy

• Previous eye surgery or injury increases the risk

of open globe injury

• Eye protection worn does NOT exclude open

globe injury

Examination ndings

• Gently open lids: exclude obvious open globe

injury or retrobulbar haemorrhage (topical

anaesthetic may facilitate this)

• Visual acuity

• Relative afferent pupillary defect (RAPD)

• Red reex

• Ocular motility (ask the patient about double

vision or pain)

• Check heart rate (oculocardiac reex from

muscle entrapment: bradycardia)

• Palpate for orbital rim tenderness (infraorbital

nerve involvement is suggested by abnormal

sensation over the cheek, upper lip or teeth)

• Orbital retropulsion but DO NOT test if open eye

injury is suspected

• Supercial ocular examination with a slit lamp

(or some magnication) to assess for corneal/

conjunctival laceration or penetration

• Further ocular examination, including dilated

fundus examination, as determined by history

and examination ndings

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Investigations

• CT orbits: look closely at the coronal and

axial sections in soft tissue and bony

windows for fracture, globe integrity or

retrobulbar haemorrhage

Important differentials

• Open globe injury

• Orbit fracture

• Closed globe injury: anterior = hyphaema or

lens dislocation

• Closed globe injury: posterior = retinal tear/

detachment, vitreous haemorrhage or

choroidal rupture

Initial treatment

• Trauma assessment: exclude

life-threatening injuries

• Assume an open globe injury until

proven otherwise

• Analgesia and antiemesis (vomiting and

other Valsalva may cause loss of intraocular

contents in an open globe injury)

Eye traumacommunication checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

Specic communication checklist

Consider the following:

; Why do you think this is an open/closed

globe injury?

; Is the patient ready for operating theatres

(considering general health, other injuries

and fasting status)?

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Chemical burns

Immediate referral to an ophthalmologist.

Ensure the following:

• Once a chemical injury is suspected, you

must commence irrigation before further

history or examination

• Exclude an open globe injury if the

mechanism is suspicious, (e.g. an explosion)

History ndings

• Time when the burn occurred

• Nature of chemical, i.e. acid/alkali (note alkalis

are more harmful to the eye)

• Any rst aid administered and when that was

done after the incident

Examination ndings

• Consider the following:

• Use topical anaesthesia if necessary

• Trichiasis (inturned eyelashes which may rub on

the cornea)

• Visual acuity

• Fluorescein staining (corneal and conjunctival)

• Cornea clear or cloudy (note iris detail visibility)

• Degree of vascular blanching, particularly at the

limbus, is proportional to the severity of the

chemical burn (see Figure 15, Figure 16 and

Figure 19 for comparison)

• Evert eyelids and note any retained

particulate matter

Investigations

• Measure pH for both eyes using universal

indicator paper in the conjunctival fornix (or a

cut-off urine dipstick if unavailable)

• Repeat pH testing after every second litre

of uids

Important differentials

• Retained particulate chemical

• Thermal injury

• Exclude open globe injury, penetrating or mixed

mechanism injuries, (e.g. explosions)

Figure 15. Acute alkali chemical injury

(mild/moderate).

Figure 16. Acute alkali chemical injury (severe).

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Initial treatment

Immediate:

Eye irrigation for chemical burns

1. Administer local anaesthetic drops to the

affected eye/eyes.

2. Commence irrigation with 1L of a neutral

solution, e.g. Hartmann’s, normal saline

(0.9%) in an IV giving set on full ow.

3. Evert the eyelid and clear the eye of any

debris or foreign body that may be present

by sweeping the conjunctival fornices with

a moistened cotton bud.

4. Irrigate from 3–5cm above the ocular

surface. Ask the patient to look left, right,

up and down whilst irrigating.

5. Use nitrous oxide/ketamine if necessary

for irrigation.

6. Review the patient’s pain level every 10

minutes and instill another drop of local

anaesthetic as required.

7. Review after 1L of irrigation administered.

8. Wait 5 minutes after ceasing the irrigation

uid then check the pH in BOTH eyes

(acceptable pH range 6.5–8.5). Compare

with unaffected eye’s pH if

unilateral injury.

9. Consult with the senior medical ofcer or

ophthalmologist and recommence

irrigation if necessary.

10. Severe burns and alkalis usually require

continuous irrigation for at least 30

minutes with 3L of uid.

Figure 17. Irrigation with the eyelid everted.

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Eye traumacommunication checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

Specic communication checklist

Consider the following:

; What chemical was involved?

; What irrigation has already

been administered?

; Have you everted the upper and

lower eyelids?

; What is the pH?

Notes

• The emergency treatment of a chemical

injury has far greater impact on the nal

ocular outcome than any other factor.

Prompt and thorough irrigation is critical to

avoiding a painful, permanently blind eye in

these patients.

• Examples of acids include toilet cleaner, car

battery uid and pool cleaner.

• Examples of alkalis include bleach, lime/

cement, mortar and plaster, drain cleaner,

oven cleaner and ammonia.

• Alkalis saponify ocular tissues and continue

to burn deeper into the eye, hence they

require more irrigation.

• For medicolegal reasons, it is important to

document when and how the injury

occurred, whether eye protection was

present and whether on-site rst aid

was given.

Figure 18. Universal indicator paper.

Figure 19. Typical long-term outcome of a severe

chemical ocular injury. While a corneal transplant

has been attempted, this has failed and become

opacied and vascularised. Limbal stem cell

damage by chemical injury results in a very poor

long-term visual prognosis.

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Closed globe injury

Urgent referral to an ophthalmologist

required<24hrs.

• History of eye surgery (assume the

patient has an open globe injury until

proven otherwise)

• Reduced visual acuity, not improved

by pinhole

• RAPD

• Loss of red reex

• Photophobia

• Photopsia (ashing lights like a camera

ash) or oaters suggesting

retinal injury

• Irregular pupil

• Difculty opening eyelids and a tense

orbit suggest retrobulbar haemorrhage

Figure 20. Hyphaema: blood in the

anterior chamber.

Important ndings

• Hyphaema

• Traumatic mydriasis

• Lens dislocation

• Loss of red reex with vitreous haemorrhage

• Retinal detachment

History ndings

• Mechanism of injury

• Timing of visual loss after injury

(immediate/delayed, stable/progressive)

• Quality of visual loss: blurring, oaters, curtain,

greying or total blackness, scotoma

• Any previous ocular surgery (this increases the

risk of open globe injury)

• Double vision: suggests muscle injury or

nerve palsy

Examination ndings

• Visual acuity

• Slit lamp examination with uorescein

• Shallow or deep anterior chamber

and hyphaema

• Red reex

• Check pupils for an RAPD and anisocoria

• Visual elds by confrontation

• Extraocular movement

• Fundus examination

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Investigations

• Check intraocular pressure (only if open

globe injury has rst been excluded)

Important differentials

• Open globe injury

• Head injury or fracture

• Orbital fracture or retrobulbar haemorrhage

• Closed globe injury: anterior = corneal

abrasion, hyphaema and lens dislocation

• Closed globe injury: posterior = retinal

detachment, vitreous haemorrhage and

choroidal rupture

Initial treatment

• Rest at 45°

• Shield the eye (do not pad)

Eye trauma communication checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

Notes

Blunt trauma to the eye may result in

considerable damage to the intraocular

contents. Fracture of the orbital wall may

occur due to the transfer of mechanical

energy to the relatively thin orbital bone.

Slit lamp examination must include uorescein

to look for leaking aqueous in open

globe injury.

Is the anterior chamber shallow or deep?

Angle a tall and thin light beam at 45º to

assess anterior chamber depth.

Consider globe ultrasound if loss of red reex

or poor visual acuity (only if open globe injury

has been excluded rst).

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Flash burns

History ndings

• Mechanism (electric arc welding or UV light,

e.g. sh tank, sun lamp or skiing without

eye protection)

• Symptoms typically appear within

several hours

• Symptoms are usually intense pain, red eye,

photophobia, blepharospasm and tearing

Examination ndings

Consider the following:

• Use topical anaesthesia in the examination

(it will usually relieve pain completely) or

small amounts of analgesia, e.g. IV opioid

or methoxyurane.

• Visual acuity: often mildly decreased (repeat

+/- pinhole after local anaesthesia).

• Slit lamp: conjunctival injection, widespread

supercial punctate epithelial defects

staining with uorescein (often bilateral).

Investigations

• Not required

Important differentials

• Chemical injury

• Corneal foreign body

Initial treatment

• Topical antibiotic drops of preservative-free

articial tears q1–2hr prn (ointment may be

soothing especially overnight)

• Cycloplegic, (e.g. cyclopentolate 1% bd) for

comfort for 2 days

• Oral analgesia as required (stronger

than paracetamol)

• Inform patients to re-present if symptoms have

not improved appreciably after 24 hours

Eye trauma communication checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

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Lid laceration

Immediate referral to an ophthalmologist.

An eyelid laceration is a

potential penetrating eye injury

until proven otherwise.

Figure 21. Exploration of an extensive

lid laceration.

Questions to ask the patient:

• Which eye is injured?

• How did it happen? Was there any

possibility of penetration into

the eye/orbit/brain?

• When did it happen?

• What are the symptoms,

(e.g. blurred vision, watery eye or red eye)?

Figure 22. Torn eyelid with avulsed lower

lacrimal canaliculus from a dog bite injury.

Examination ndings

• Wound examination (size and depth, tissues

visualised, e.g. skin, muscle or septum)

• Visual acuity

• Supercial ocular examination with a slit lamp

(or some magnication) and uorescein to

assess for any corneal/conjunctival laceration

or penetration

• Further ocular examination including the extent

of lid closure, eye movements and dilated

fundus examination as determined by history

and examination ndings

• Always consider the possibility of a retained

foreign body

Investigations

• Orbital CT if suspicious for foreign bodies or

orbital fracture (plain X-ray has poor sensitivity)

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Important differentials

• An eyelid laceration is a potential penetrating

eye injury until proven otherwise.

• Note the extension of injury to surrounding

tissues (globe, orbit, lacrimal drainage

apparatus, paranasal sinuses and brain).

Initial treatment

• Any laceration other than supercial skin will

need an ophthalmic referral

• Involvement of the medial eyelid (where the

lacrimal drainage apparatus resides) or of the

eyelid margin requires ophthalmic referral within

48 hours for repair

• Check for tetanus immunisation status

Treatment if supercial laceration does not involve

the lid margin or lacrimal drainage apparatus:

1. Clean the area and surrounding skin with

antiseptic such as Betadine.

2. Subcutaneous anaesthetic with a

vasoconstrictor (2% lignocaine with adrenaline).

3. Irrigate and debride the wound thoroughly

with saline.

4. Remove foreign bodies if applicable.

5. Suture with a 6/0 non-absorbable suture.

6. Remove sutures within 5 days.

Eye trauma communication checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

Specic communication checklist

Consider the following:

; Where is the laceration?

; Is it full thickness (involving the lid margin)

or medial to the puncta?

Notes

Eyelid lacerations can cause visual loss from

corneal scarring and permanent discomfort

from poorly functioning eyelids, or recurrent

infection and watering if there is damage to

the lacrimal drainage system.

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Non-accidental injury (NAI)

Seek immediate referral to the

ophthalmologiston the same day.

Referral urgency: immediate to

the child protection unit.

History ndings

• The stated mechanism of injury is

inconsistent with examination ndings

• Changing history of injury

• Recurrent or delayed hospital presentations

Figure 23. Fundus photographs of retinal

haemorrhages in neonates with a history of

birth asphyxia and amniotic uid aspiration.

Figure 24. Peripapillary white-centred

retinal haemorrhages.

Initial treatment

In a suspected NAI in a child, ensure:

• urgent referral to an appropriate paediatric team

and child protection unit for multi-disciplinary

assessment and management

• an ophthalmologist review for fundoscopic signs

of trauma is required as part of the work-up.

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Open globe injury

(penetratingeye injury)

Seek an immediate referral to an ophthalmologist.

History ndings

• Mechanism (small objects moving fast are more

likely to cause a penetrating eye injury)

• Timing of visual disturbance after the injury

Examination ndings

• Examination may only need to be cursory if the

trauma is obvious

• Visual acuity and RAPD

• Direct ophthalmoscopy (loss of red reex may

suggest retinal trauma or detachment)

• Slit lamp with uorescein (looking for distorted

anterior chamber structures, corneal/scleral

breaks and Seidel test)

Figure 25. Penetrating eye injury, with a small

amount of iris tissue extruding through the

corneal wound. Also note the teardrop-shaped

pupil and the lens opacication.

Photograph courtesy of Lawrence B. Stack, MD, Professor of

Emergency Medicine and Paediatrics, Vanderbilt University Medical

Center, Nashville, Tennessee, USA.

Figure 26. Seidel test positive: the observation of

the ocular surface stained with 2% uorescein

under diffuse, bright cobalt blue light reveals a

waterfall-like effect as clear aqueous exudes

through a penetrating corneal wound and

displaces the uorescein-stained tear lm.

Figure 27. Penetrating eye injury, with iris tissue

extruding through the corneal wound. Note the

tear-drop pupil. The eye is otherwise uninamed,

with the cornea and lens both clear.

Photograph courtesy of Lawrence B. Stack, MD, Professor of

Emergency Medicine and Paediatrics, Vanderbilt University Medical

Center, Nashville, Tennessee, USA.

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Initial treatment

• Shield the eye (do not use a pad) to avoid

inadvertent pressure on the globe

• Antiemetic to avoid expulsion of ocular contents

• Analgesia if required

• IV antibiotics (broad spectrum)

• Tetanus prophylaxis

• Keep nil by mouth, strict bedrest and prepare

for theatre

• No ointment for penetrating eye injury

• Consider a ne-cut orbital CT scan to look for a

foreign body

Eye trauma communication checklist

Follow ISBAR:

; What is the mechanism of trauma?

; Are you concerned about an open

globe injury?

; Is there a history of previous eye surgery

or injury?

; What is the visual acuity (including with

pinhole if not 6/6)?

; Is there an RAPD?

; What are the ndings on slit lamp

examination with uorescein?

; Does the patient have other injuries?

; What treatment has been commenced?

Specic communication checklist

Consider the following:

; What was the likely cause?

; Is there a positive Seidel test?

; Is there a retained foreign body/bodies

clinically or on CT?

; When has the patient fasted from?

Notes

• The pupil may point towards a corneal

perforation or be irregular.

• There may be an iris defect or early lens

opacication visible when examining the

red reex carefully.

• Fluorescein will light up in a waterfall-like

appearance from a leaking corneal wound

(Seidel sign). An entry wound may not be

obvious and may be hidden by conjunctival

tissue or subconjunctival haemorrhage.

• The anterior chamber may be shallow for

anterior injuries or very deep for posterior

injuries (compare with the other eye).

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Orbital fracture

Immediate referral (phone) if reduced

vision, reduced heart rate (or vomiting)

on up-gaze, evidence of retrobulbar

haemorrhage.

Seek an urgent referral to an

ophthalmologist <24hr.

Refer to plastic surgery or maxillofacial

surgery for consideration of orbital

fracture repair.

Important ndings

• Poor visual acuity

• Difculty opening eyelids (retrobulbar

haemorrhage)

• Haemodynamic instability or vasovagal

syndrome (entrapment of extraocular muscle,

usually inferior rectus)

• Exclude head/intracranial injury

History ndings

• Mechanism of trauma, including the possible

presence of a foreign body, visual disturbance or

any diplopia (double vision)

• Photopsia (light ashes) or oaters (suggestive

of retinal injury)

• Any previous eye surgery (this increases the risk

of an open globe injury)

Examination ndings

• Gently open lids to exclude obvious open globe

injury or retrobulbar haemorrhage

• Visual acuity (also test with pinhole if not 6/6)

• RAPD

• Red reex

• Ocular motility (ask the patient about double

vision or pain)

• Check heart rate (oculocardiac reex)

• Palpate orbital rim tenderness (infraorbital

nerve involvement is suggested by abnormal

sensation over the cheek, upper lip or teeth)

• Retropulsion if open globe injury has

been excluded

• Supercial ocular examination with a slit lamp

(or some magnication) to assess for any

corneal or conjunctival laceration or penetration

• Intraocular pressure check if open globe injury

has been excluded

• Fundus examination (do not dilate until

intracranial injury is excluded and visual acuity

and RAPD are checked)

Investigations

• CT orbits and ne brain slices: look closely at

the coronal and axial sections in soft tissue

windows for fracture, globe integrity or

retrobulbar haemorrhage

Important differentials

• Retrobulbar haemorrhage

• Open globe injury

• Associated closed globe injury

(up to 30% of cases)

Initial treatment

• Analgesia

• No nose blowing (cough/sneeze with open

mouth to avoid an increase in sinus pressure,

which may displace non-sterile material through

fracture and into orbit)

• Broad-spectrum IV antibiotics (see next)

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Figure 28. Coronal CT scan: left blow-out fracture.

Figure 29. Blow-out fracture: squash ball hit to

the eye.

Notes

• Discharge on oral antibiotics,

(e.g. Augmentin Duo bd for 7 days) and

nasal decongestant spray.

• Gentle ice pack to the orbit for

24–48 hours.

• Surgical repair, if necessary, is usually

performed 7 to 14 days after trauma.

Indications for surgical repair of orbital

oor fracture:

• Immediate repair: oculocardiac reex

in a young patient with white-eyed

blow-out (greenstick) fracture and

entrapped muscle.

• Early repair (<2/52): persistent diplopia,

enophthalmos and hypoglobus.

• Observation only: minimal diplopia

(especially if limited to up-gaze).

Things to consider:

• The force required to cause orbital

fracture is often signicant enough to also

cause closed-eye injuries. Perform an

adequate ocular examination, including

intraocular pressure.

• The medial wall is thinnest and tends to

blow out rst but rarely requires

surgical intervention.

• The orbital oor is the second most

common and can often disturb eye position

and movements.

• The lateral wall and roof are more robust

and tend to fracture only in

higher-force injuries.

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Retrobulbar haemorrhage

(orbital compartment syndrome)

Seek an immediate referral to an ophthalmologist.

Consider the following:

• Are there systemic or

intracranial injuries?

• Is the patient on anticoagulants? If so,

this increases the likely need

for intervention.

Examination ndings

• Tense orbit: difculty opening eyelids with

your ngers

• Haemorrhage conned to the orbital rim

• Chemosis (conjunctival swelling)

• Raised intraocular pressure and resistance to

retropulsion: press your index nger against

each globe through the closed lids

• Limited ocular motility, i.e. pain or diplopia

(double vision)

• Reduced vision: if severely reduced vision,

consider immediate treatment

• RAPD: if present, consider immediate treatment

• Progression in any of the above ndings

over time

Investigations

• Intraocular pressure: check with a tonometer

if available

CT orbits and brain: do not delay intervention for CT

if clinically suggestive of vision-threatening

retrobulbar haemorrhage.

Figure 30. Retrobulbar haematoma causing globe

proptosis. The involved globe appears smaller

because it has been pushed superiorly or

inferiorly out of the CT slice.

Important differentials

• Open globe injury

Initial treatment

Video - Canthotomy and cantholysis

1. Topical anaesthetic drops: repeat until no sting

on instillation.

2. Subcutaneous local anaesthetic with

adrenaline, (e.g. 2% lignocaine with adrenaline)

to lateral upper and lower eyelid insertions,

deeply to reach the inner aspect of the lateral

orbital rim and subconjunctivally if possible.

Always point away from the globe.

3. Use artery clamp to clamp over lateral canthus

(extending along the eyelid in a ‘Cleopatra line’)

for several seconds.

4. Use sharp-tipped scissors to cut laterally for

1–2cm along the clamped line.

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5. Hold the lower lid taught with forceps and blunt

dissect between the orbicularis oculi muscle

and lateral canthal tendon.

6. Strum the closed scissors over the tendon

(anteroposterior). When the lateral canthal

tendon has been identied, place each blade of

the scissors on either side, (i.e. one in the

conjunctival fornix and the other in the pocket

between orbicularis and tendon) aiming

inferiorly and cut.

7. Ensure the lower lid is lax with eyelids

readily openable.

8. Apply Chlorsig ointment and an

absorbent dressing.

9. Continue pupil and hourly vision observations.

Specic communication checklist

Consider the following:

; When did the injury occur?

; Are there other systemic or head injuries?

; Is the patient on anticoagulants?

; Do/did you need to perform canthotomy

and cantholysis IMMEDIATELY (dependent

on examination ndings as above)?

Notes

Consider the following:

• Visual outcomes are better in some case

series if canthotomy and cantholysis are

performed within 2 hours of injury.

• When examining a CT of the orbits, check

both the axial and coronal slices using soft

tissue windows. Hyperdensity around the

optic nerve, with proptosis, is suggestive of

retrobulbar haemorrhage.

• Orbital compartment syndrome may be

worse if there are any minimally displaced

orbital fractures. A signicant ‘blow-out’

fracture will usually decompress the orbit.

• The main indication for a canthotomy and

cantholysis is evidence of end-organ

compromise, e.g. reduced visual acuity, an

RAPD or evolving motility disturbance.

Acute visual

disturbance

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Acute visual disturbance

Third (3rd) cranial nerve palsy

Seek an urgent referral to an ophthalmologist <24hr.

Giant cell arteritis (GCA) is a cause of an

isolated 3rd cranial nerve palsy and, if

missed, can lead to irreversible blindness in

one or both eyes. You must specically ask

the patient about GCA symptoms and

document this in the medical record.

A 3rd cranial nerve palsy can be a sign of

raised intracranial pressure. You must ask

about headache symptoms and examine

the optic disc for signs of optic

disc swelling.

Don’t forget to check the other cranial

nerves and ask and look for any other

neurological decits.

Figure 31. Images show right ptosis and 3rd

cranial nerve palsy. The right eyelid is being

pulled up.

History ndings

• Vertical and horizontal diplopia (double vision):

note patient may not experience any double

vision if they are experiencing complete ptosis

• Complete/partial ptosis

• May have headache and pain

• In patients >60 years, enquire specically about

GCA symptoms

Examination ndings

• Ptosis (complete/partial)

• Pupil (may or may not be dilated)

• Ocular motility: the eye looks down and out in

primary gaze suggests ophthalmoplegia except

for abduction and intorsion

• Examine the remainder of cranial nerves to

determine if isolated 3rd cranial nerve palsy or

part of multiple cranial nerve palsies

Investigations

• Cardiovascular risk factor work-up

• Fine-cut CTA of Circle of Willis, looking for

aneurysm with pupil involvement

Important differentials

• Pituitary apoplexy

• Posterior communicating artery aneurysm

• Vasculitis

• Thyroid eye disease

• Myasthenia gravis

• Horner’s syndrome (partial ptosis and

normal motility)

• Compression neoplasm

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Initial treatment

• Liaise with neurology

• Inform the patient that it is illegal to drive while

experiencing diplopia

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history

; Visual acuity (with pinhole if not 6/6)

; Visual elds (by confrontation)

; Pupil examination: anisocoria and relative

afferent pupillary defect (RAPD)

; Red reex

; Dilated retinal examination

; Eyelid examination ndings

(complete/partial ptosis)

; Ocular motility ndings

Fourth (4th) cranial nerve palsy

Seek an urgent referral to an ophthalmologist <24hr.

Giant cell arteritis (GCA) is a cause of an

isolated 4th cranial nerve palsy and, if

missed, can lead to irreversible blindness in

one or both eyes. You must specically ask

the patient about GCA symptoms and

document this in their medical record.

A 4th cranial nerve palsy can be a sign of

raised intracranial pressure. You must ask

about headache symptoms and examine

the optic disc for signs of optic

disc swelling.

Don’t forget to check the other cranial

nerves and ask and look for any other

neurological decits.

History ndings

Consider the following:

• Vertical and/or torsional diplopia: the patient

may describe that images appear tilted/objects

appear in their vision and as leaning to one side.

• Ask about the onset, duration and

improvement/worsening.

• Ask about a history of trauma, head injury

and falls.

• Ask about cardiovascular risk factors,

particularly diabetes.

• Ask about the presence of any GCA symptoms.

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Examination ndings

• Visual acuity

• Check for RAPD (or RAPD with orbital apex/

cavernous sinus lesion)

• Evidence of head tilt (consider posture and

compare with old photos to

determine chronicity)

• Extraocular movement examination

• Examine the remainder of cranial nerves to

determine if isolated 4th nerve palsy or part of

multiple cranial nerve palsies

Investigations

• Cardiovascular risk factor work-up

• Neuroimaging (CT brain)

Important differentials

• GCA

• Thyroid eye disease

• Myasthenia gravis

• Microvascular

• Trauma

• Congenital

Initial treatment

• Depends on the underlying cause

• Liaise with neurology

• Inform the patient that it is illegal to drive while

experiencing diplopia

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes and how well it has

been managed)

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination (anisocoria or presence

of RAPD)

; Red reex

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Sixth (6th) cranial nerve palsy

Seek an urgent referral to an ophthalmologist <24hr.

Giant cell arteritis (GCA) is a cause of an

isolated 6th cranial nerve palsy and if

missed can lead to irreversible blindness in

one or both eyes. You must specically ask

the patient about GCA symptoms and

document this in their medical record.

A 6th cranial nerve palsy can be a sign of

raised intracranial pressure. You must ask

about headache symptoms and examine

the optic disc for signs of optic

disc swelling.

Don’t forget to check the other cranial

nerves and ask and look for any other

neurological decits.

Figure 32. Patient with 6th cranial nerve palsy.

History ndings

Consider the following:

• Horizontal diplopia (double vision) presents as

worse for distance than near, and worse looking

towards the affected side. The patient may

describe double vision whilst driving, watching

television or looking out the window.

• Assess for any headache, morning nausea or

vomiting (raised intracranial pressure).

• Assess for any GCA symptoms.

Examination ndings

• Visual acuity

• Extraocular movements: check for limited

abduction and other directions of gaze

• Pupils normal/not normal: anisocoria or RAPD

• Eyelid positions (no ptosis)

• Exclude swollen optic discs (6th cranial nerve

palsy may be caused by raised intracranial

pressure)

• Examine the remainder of cranial nerves to

determine if isolated 6th cranial nerve palsy or

part of multiple cranial nerve palsies

Investigations

• Cardiovascular risk factor work-up

• CT brain

• Urgent ESR and CRP blood tests if GCA

is suspected

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Important differentials

• GCA

• Raised intracranial pressure

(e.g., space-occupying lesions)

• Myasthenia gravis

• Trauma

Initial treatment

• Depends on the underlying cause

• Liaise with neurology

• Inform the patient that it is illegal to drive while

experiencing diplopia

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history

(particularly diabetes and how well

it has been managed)

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Ocular motility looking for difculty

abducting the eye, (i.e. looking away from

the nose)

Central retinal artery occlusion

(CRAO)

Seek an immediate referral to an ophthalmologist.

If the patient has giant cell arteritis (GCA)

symptoms, urgent blood tests including

ESR and CRP should be ordered.

Figure 33. Area of cilioretinal sparing (top line)

and ‘cherry red spot’ (lower line).

Area of cilioretinal sparing

"Cherry red spot"

History ndings

• Sudden, painless and persistent loss of vision

• GCA symptoms if >50 years of age

• Cardiovascular risk factors

Examination ndings

• Poor acuity (may have central sparing)

• Marked RAPD

• Fundus examination: may have minimal signs

on fundoscopy

• Pale retina with a cherry red spot and arteriolar

and venular narrowing

• Abnormal temporal artery (if suspected GCA)

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Investigations

• GCA may cause CRAO: check ESR, CRP and FBC

• Cardiovascular risk factor work-up

• Important differentials

• GCA may co-exist with CRAO

Initial treatment

• Urgent discussion with the ophthalmology team,

especially within 4 hours of the onset of

symptoms, as certain sight-saving treatments

may be attempted

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

GCA symptom list

• Polymyalgia rheumatica

• New onset headache (often temporal)

• Scalp tenderness

• Jaw claudication

• Tongue claudication

• Fever and night sweats

• Loss of weight

• Generalised muscle pain and weakness

• Possible diplopia (double vision) or transient

visual loss

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Central retinal vein occlusion

(CRVO)

Seek immediate referral by phone to

an ophthalmologist.

Check for high blood pressure.

Figure 34. From top to bottom: dilated tortuous

veins; disc swelling; cotton wool spots; intra-

retinal haemorrhage (visible in all four quadrants).

Dilated tortuous veins

Cotton wool

spots

Disc

swelling

Intra retinal

haemorrhage

(visible in all four

quadrants)

Figure 35. Severe CRVO: haemorrhages obscure

much of fundus detail.

History ndings

• Sudden and painless loss of vision

• Cardiovascular risk factors

• Increasing age

• Glaucoma

Examination ndings

• Visual acuity

• Pupil examination: important prognostic factor

(RAPD)

• May see prominent iris vessels and red eye

(if long-standing)

• Fundus examination shows multiple areas

of haemorrhage

• Intraocular pressure

• Blood pressure

Investigations

• Blood glucose

• Lipids

Important differentials

• Vitreous haemorrhage

• Central retinal artery occlusion

• Giant cell arteritis (GCA)

• Malignant hypertension

(preeclampsia in gravid women)

Initial treatment

• Discuss the case with the ophthalmology team

for referral urgency

• Screen for diabetes and hypertension

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Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination

; Intraocular pressure

Central serous chorioretinopathy

Consider other diagnoses if signicantly

reduced vision or an elderly patient.

Figure 36. Central serous retinopathy in a retina,

imaged using optical coherence tomography

(OCT; vitreous side is at top of image).

History ndings

• Usually young men with a Type A personality

• Central scotoma, metamorphopsia

• May have had a previous episode

• Corticosteroid (any form) use, including topical

or inhaled

Examination ndings

• Reduced visual acuity to around 6/9 or 6/12,

improving a little with pinhole (Amsler grid

shows a relative scotoma or distortion of lines)

• May present with hyperopic refractive shift/

trouble reading, micropsia and colour

vision changes

• Ocular examination otherwise normal

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Important differentials

• Malignant hypertension

• Choroidal neovascularisation

• Macular haemorrhage

• Macula-off retinal detachment

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination if instructed

; Amsler grid nding

Dry eye/exposure keratopathy

Dry eye is a common chronic ocular condition that

is often caused by, or coexists with, other ocular

diseases. Dry eye may cause temporary, reversible

and minor acute visual disturbance.

Figure 37. Dry eye showing diffuse punctate

staining with uorescein.

Figure 38. Mucus strand is also visible across

thecornea.

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History ndings

• Sensation of dry eye, eye pain and intermittent

blurred vision that improves with blinking or

lubricating drops

• Symptoms often worsen in the evening, in

air-conditioned or windy environments, and with

tasks requiring prolonged concentration (with

reduced blink rate)

• Usually bilateral

Examination ndings

Consider the following:

• Visual acuity may be slightly reduced (6/6–6/12)

and may improve with lubricating drops.

• Punctate uorescein staining in interpalpebral

ssure (lower third of cornea). Staining may vary

from no staining or a few punctate erosions, to

severe diffuse corneal and conjunctival staining.

• Coexisting posterior blepharitis is often present.

Important differentials

• Chemical burn

• Eyedrop toxicity (especially preserved drops)

• Contact lens-related problem (overwear or

solution sensitivity)

• Exposure keratopathy

• Flash burn

• Microbial keratitis

Initial treatment

• Lubricating drops, gels or ointments prn

(preserved or preservative-free)

• Reduce exposure to drying conditions (see

History section above)

• Treat any co-existing blepharitis

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination

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Giant cell arteritis (GCA)/

anteriorischaemic optic

neuropathy (AION)

Seek immediate referral by phone to

an ophthalmologist.

• Sudden profound loss of vision

• Constitutional symptoms of giant cell

arteritis (GCA)

• History of intermittent visual loss

• Age >50yrs

Figure 39. Swollen and pale optic disc (shown left)

with a disc margin haemorrhage (shown right).

Haemorrhage

Swollen optic disc

History ndings

• Affects patients older than 50 years of age

• May have polymyalgia rheumatica

• New onset headache (often temporal)

• Scalp tenderness

• Jaw claudication

• Tongue claudication

• Fever and night sweats

• Weight loss

• May have diplopia (double vision) or

transient visual loss

Examination ndings

May include any or all of the following:

• RAPD

• Poor visual acuity, often counting ngers or light

perception (may also be normal)

• Tender and non-pulsatile temporal artery

• Swollen pale optic disc

Investigations

• Immediate ESR and CRP (both/either may

be elevated)

• FBC (high platelet count), EUC, LFT and BSL

(in planning for steroid treatment)

• Plan for temporal artery biopsy (within 1 week)

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Important differentials

• Central retinal artery occlusion (CRAO)

• Non-arteritic anterior ischaemic optic

neuropathy (AION)

Initial treatment

Due to the potential risk of severe and irreversible

blindness, urgent intravenous corticosteroids

should be considered if the diagnosis is likely,

especially if the patient has visual symptoms or a

demonstrated loss of vision.

Urgent referral is required to a rheumatologist and

an ophthalmologist (especially if any visual

symptoms or visual loss).

Specic communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Ask the patient about GCA symptoms

; Past ocular/medical history (particularly

diabetes and how well it has been managed)

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

Idiopathic intracranial

hypertension (IIH):

transientvisual obscuration

Seek immediate referral by phone to an

ophthalmologist < 24hr.

May lead to permanent loss of vision,

severe headache, neurological signs

and drowsiness.

Figure 40. Optic disc swelling (note blurred

disc margins).

Swollen optic disc

History ndings

• Headache, worse in the morning or lying supine

• Transient visual obscuration (seconds)

• Pulsatile tinnitus

• Medication such as oral contraceptive pills,

vitamin A derivatives and tetracyclines

• Most commonly affects young,

overweight females

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Examination ndings

• Visual acuity is often normal unless advanced

• Visual eld testing (by confrontation) and needs

automated perimetry in private rooms, public

hospital or other eye service

• Pupil examination (RAPD may be absent if

symmetrical optic nerve damage)

• Extraocular movement (may have 6th cranial

nerve palsy or palsies)

• Increased body mass index (weigh the patient)

• Swollen optic disc/s

Investigations

• Blood pressure

• Brain MRI/MRV diagnostics

• Lumbar puncture to check opening pressure

Important differentials

• Venous sinus thrombosis

• Intracranial space-occupying lesion

• Thyroid eye disease

• Lymphoma

• Giant cell arteritis (GCA) if >50 years old

Initial treatment

• Liaise with the ophthalmology team urgently if

the optic nerve is compromised (reduced vision,

RAPD or colour vision change)

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation) and also

need automated perimetry at private

rooms, public hospital or other eye service

; Pupil examination: anisocoria or RAPD

; Red reex

Specic communication checklist

Consider the following:

; Field loss

; Optic disc appearances

; Weight and BMI

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Intermittent angle closure/

acuteangle closure

Seek an immediate referral to an ophthalmologist.

Reduced vision and unwell, (e.g. nausea

and vomiting).

Figure 41. Conjunctival vessels dilated at the

corneal edge (ciliary ush and circumcorneal

ush) and hazy cornea characteristic of acute

angle closure, where intermittent is a variant.

History ndings

• Usually South East Asian background

• May have signicant glare, a history of eye pain

or blurry vision in dim light

• Uncommon in patients who have had

cataract surgery

Examination ndings

Consider the following:

• Reduced visual acuity, abnormal red reex,

+/- RAPD (if developed retinal complications)

• May also have xed and dilated pupil

• The cornea appears cloudy

• Raised intraocular pressure (if it can be

measured) and the globe may feel rm

on palpation.

Initial treatment

• Liaise with an ophthalmologist

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

Specic communication checklist

Consider the following:

; Slit lamp examination

; Check for a sulphur allergy if treatment

with acetazolamide (diamox) is considered

Notes

Avoid dilating patients with suspected

narrow angles.

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Lens subluxation

History of ocular trauma and systemic

associations, such as Marfan syndrome.

History ndings

• Reduced vision

• Monocular diplopia (double vision)

• History of eye/head trauma

• Pseudoexfoliation syndrome

• Ocular surgery

• Medical history (Marfan syndrome

or homocystinuria)

Examination ndings

• Visual acuity

• Check intraocular pressure if possible:

RAPD should be absent

• Dilated examination, if instructed by the

ophthalmology team, shows a subluxed lens

or intraocular lens implant

• Assess for associated ocular injury if caused

by trauma

• Physical examination to check features of

Marfan syndrome

Investigations

• Marfan syndrome or homocystinuria work up

if suspected clinically

Important differentials

• Acute angle closure crisis

• Uveitic glaucoma

• Eccentric pupil

• Penetrating eye injury

Initial treatment

• Consult the ophthalmology team to establish the

diagnosis, underlying cause and management

Specic communication checklist

Consider the following:

; Medical history

; Ocular history

; Visual acuity

; Pupil assessment

; Anterior segment ndings (dilated

examination if instructed by the

ophthalmology team) and intraocular

pressure if able to obtain

; Physical examination to look for Marfan

syndrome features

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Macular haemorrhage in wet

age-related macular degeneration

Seek an immediate referral to an ophthalmologist.

History of age-related macular degeneration.

History ndings

• Sudden, persistent, unilateral, painless loss of

central vision

• History of macular degeneration (may be on

intravitreal anti-VEGF injections)

• May be on anticoagulants

Examination ndings

• Reduced visual acuity with relatively intact or

unaffected peripheral vision

• Central scotoma on Amsler grid

• Pupil examination: RAPD may be present

Figure 42. Central scotoma on Amsler grid.

Important differentials

• Central retinal vein occlusion

• Central retinal artery occlusion

• Haematological malignancy

• Diabetic retinopathy

• Other macular pathology

Initial treatment

• Contact an ophthalmologist to establish

the diagnosis

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination

Specic communication checklist

Consider the following:

; Medical history: anticoagulant use

; Peripheral vision

; Amsler grid nding

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Macular pathology

The macula is the central region of the retina

and is responsible for central vision. People with

macular conditions are usually symptomatic,

often with reduced visual acuity on Snellen

chart testing. The onset can be acute or chronic.

A detailed posterior segment examination,

including dilation of the pupils and, often, the

use of imaging techniques such as optical

coherence tomography, will aid the diagnosis of

the specic type of macular pathology.

Conditions to consider include macular

haemorrhage, macular hole, epiretinal

membrane, dry age related macular

degeneration, central serous retinopathy,

macular oedema due to diabetic retinopathy and

post-operative macular oedema.

Migraine

Poor vision, neurological symptoms, age>50

and visual disturbance of more than 1 hour.

History ndings

• Headache (unilateral)/throbbing headache

• Nausea and vomiting

• Visual aura (typically precedes migraine onset

and lasts 15–20 minutes)

• Flashes after visual aura

• Central scotoma

• Other neurological symptoms

Examination ndings

• Normal ocular examination

• May present with a scotoma on visual eld

assessment whilst experiencing a

migrainous aura

Important differentials

• Acute angle closure

• Malignant hypertension

• Raised intracranial pressure

• Meningitis

• Central nervous system lesion

Initial treatment

• Consult neurology team

Specic communication checklist

Consider the following:

; Headache

; Medical history and neurological symptoms

; Visual acuity, RAPD and red reex

; Ocular movement

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Myasthenia gravis

Seek immediate referral by phone to an

ophthalmologist < 24hr.

May be associated with respiratory

distress or difculty swallowing.

Figure 43. Patient with ocular myasthenia gravis.

History ndings

• Double vision and ptosis

• Variability of symptoms (worse towards the end

of the day)

• Systemic symptoms (dysphagia, limb weakness

and difculty breathing)

• Fatigability (particularly of the eyelids causing

variable ptosis)

Examination ndings

• Ptosis

• Ocular motility is abnormal, but not 3rd, 4th or

6th cranial nerve palsy pattern (although

myasthenia gravis can mimic these)

• Ice test

• Pupil examination (should be normal; consider

another diagnosis if not)

• Fatigability of lids with sustained up-gaze

(1–2 minutes)

Investigations

• Anti-Ach receptor (AChR) antibody

• Anti-MuSK antibody (muscle-specic kinase)

• Thyroid function tests

Important differentials

• Thyroid eye disease

• Other cranial nerve palsies

• Orbital lesions

Initial treatment

• Discuss with neurology

• Ophthalmology consultation regarding diplopia

(double vision) and ptosis management

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

Specic communication checklist

Consider the following:

; Medical, ocular history (especially any

variability of symptoms and fatigability)

; Pupil assessment

; Extraocular movement assessment

; Ptosis measurement

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Optic neuritis

Seek an immediate referral by phone to an

ophthalmologist < 24hr.

Atypical optic neuritis features (consider

other diagnoses): bilateral, rapid onset,

systemic symptoms, male, Southeast

Asian background, age >50 (consider

giant cell arteritis (GCA) and profound

visual loss).

Figure 44. Optic neuritis shows a swollen optic

disc and blurred disc margins.

Swollen optic disc

History ndings

• Painless vision loss over hours to days

• Vision loss can be subtle or profound (atypical)

• Reduced visual acuity (blurring), reduced colour

vision and contrast vision

• Usually unilateral but may rarely be bilateral

• Often affects females aged 18–45 years old

• Retrobulbar pain is usually associated with eye

movement and can occur before visual loss

• May have other focal neurological symptoms

relating to demyelination

Examination ndings

• Decreased visual acuity (test with pinhole if

not 6/6)

• Pupil examination (RAPD) tested prior to dilation

• Decreased colour vision

• Possible patchy scotoma but any eld defect is

possible and may be difcult to elicit

on confrontation

• Other focal neurological signs relating to

demyelination are possible

• Check blood pressure

Investigation

• Discussion with neurology if medical imaging

is needed

• Further investigations as per the neurology team

• Consider inammatory and infective causes of

optic neuritis

Important differentials

Consider the following:

• Neuromyelitis optica (in Asian populations with

profound visual loss and bilateral involvement).

• GCA is possible (in older patients).

• Vasculitis is possible.

• Other causes of swollen optic disc, (e.g. GCA,

raised intracranial pressure, idiopathic

intracranial hypertension, systemic

hypertension, central retinal vein occlusion,

thyroid eye disease and diabetic papillitis).

Initial treatment

• Discuss with the neurology team for

further investigations

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Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination if instructed

Specic communication checklist

Consider the following:

; Neurological examination

; Extraocular movements

; Appearance of optic disc

Posterior vitreous detachment

(PVD)

Seek an immediate referral by phone to an

ophthalmologist < 24hr.

Consider other diagnoses if there is visual

acuity loss or visual eld loss.

History ndings

Consider the following:

• Peripheral ashes (usually temporal) and

differentiate from migraine ‘ashes’, which last

several minutes, tend to scintillate, spread

across the visual eld, may be multi-coloured

and are often associated with an adjacent

scotoma or blurring of vision.

• Patients often cannot discern whether

monocular or binocular in origin. Migraines

sometimes do not have associated headaches,

nausea or vomiting.

• The presence of oaters.

• PVD is usually unilateral and painless. Possible

precipitating mild head or eye trauma.

• No neurological symptoms.

Examination ndings

• Visual acuity

• Check red reex (vitreous blood may be seen

oating behind the lens; retinal detachment can

cause loss of the red reex)

• Visual elds (by confrontation)

• Pupil examination: RAPD should not be present

• Dilated retinal examination

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Important differentials

• Retinal tear/break

• Retinal detachment

Initial treatment

• Liaise with an ophthalmologist

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history (particularly

diabetes) and how well it has been managed

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination if instructed

Specic communication checklist

Consider the following:

; History: peripheral ashes and/or oater/s

; RAPD or red reex

; No other neurological symptoms

Notes

• This is a common condition caused by

liquefaction of vitreous with age. It tends to

occur in 50–60-year olds.

• The ‘ashes’ symptom reects active

vitreous traction on the retina.

• Complete vitreous detachment can take up

to 6 weeks to occur.

• The majority of patients have no long-term

consequences from PVD. A small

percentage may develop a retinal

detachment. Consequently, patients with

new onset of ashes or oaters should be

examined by an ophthalmologist within

24–48 hours. If there is reduced visual

acuity, visual eld loss, blood visible in the

vitreous or other suspicious ndings on

history/examination, please liaise with an

ophthalmologist as more urgent review

may be required.

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Retinal tear or detachment

Seek an immediate referral to an ophthalmologist.

Curtaining and loss of vision.

Figure 45. Retinal detachment (macula off).

The lower end of the lines delineates the inferior

edge of the retinal detachment. The macula is

justinvolved.

Area of attached

retina - choroidal

detail still visible

Detached

retina-loss

of transparency

Figure 46. Subtotal retinal detachment.

History ndings

Consider the following:

• Painless loss of vision: the patient may have a

recent history of increased number of visual

oaters and/or visual ashes.

• There may be a ‘dark shadow’ in the peripheral

visual eld of the affected eye.

• High-risk groups are patients who are myopic

(short-sighted), who have had blunt eye/head

trauma and who have a history of retinal

detachment or eye procedures

Examination ndings

Consider the following:

• Reduced visual acuity if the macula is detached.

If not involved (‘macula on’), the vision is often

6/6. This is a more urgent condition as the

macula can be saved with early surgery.

• Loss of red reex: a mobile detached retina may

be visible on ophthalmoscopy

• Pupil examination is required for RAPD

• Visual eld defects that correspond to the area

of the detached retina can usually be elicited by

confrontation testing

• Often normal anterior segment slit lamp

examination

• Dilated retinal examination: it is generally safe to

dilate these patients once the above

examination has been completed

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Important differentials

• Posterior vitreous detachment

• Retinal vein or artery occlusion

• Stroke

• Giant cell arteritis (GCA)

• Optic neuritis

• Diabetic retinopathy (tractional detachment or

vitreous haemorrhage)

Initial treatment

• Liaise with ophthalmologist

• Keep the patient nil by mouth for

the possibility of emergency surgery

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination

Specic communication checklist

Consider the following:

; History and risk factors

; Prior cataract or other eye surgery

; Onset of symptoms

; Fasting time

Thyroid eye disease

Loss of vision or incomplete eyelid

closure should prompt an urgent referral

to an ophthalmologist.

Figure 47. Bilateral proptosis (exophthalmos), as

well as asymmetrical eye alignment indicative of

eye muscle neuromuscular involvement.

History ndings

• Known Graves’ disease

• Diplopia (double vision), red eye or painful eye

• Blurred vision

• Systemic symptoms of hyperthyroidism

• Smoking history

Examination ndings

• Visual acuity

• Proptosis

• Incomplete lid closure

• Strabismus

• Compressive optic neuropathy

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• Possible corneal ulcer from exposure of the

cornea from incomplete eyelid closure

• Optic nerve function assessment

• RAPD

• Extraocular muscle palsy

Investigations

• Thyroid function test

• CT orbit if proptosis, red eye

• FBC, LFT, EUC and BSL blood tests in planning

for corticosteroid treatment

Important differentials

• Orbital cellulitis or trauma

• Orbital tumour

Initial treatment

• Immediate ophthalmology consultation is

required if reduced vision (to assess for

compressive optic neuropathy) and for urgent

treatment (if corneal ulcers present)

Specic communication checklist

Consider the following:

; Medical, ocular history

; Visual acuity, red reex, RAPD and

ocular motility

Transient ischaemic attack

(amaurosis fugax) or

retinal emboli

Seek an urgent referral to an

ophthalmologist<24hrs.

Giant cell arteritis (GCA) symptoms,

neurological symptoms and

recurrent episodes.

Referral to neurology/cardiology or vascular

surgery as appropriate. Patients with recurrent

episodes of amaurosis fugax require immediate

diagnostic and therapeutic intervention.

Figure 48. Transient ischaemic attack.

Lines point to visible emboli.

Emboli

History ndings

• Painless, monocular visual loss lasting less than

30 minutes before returning to normal

• Cardiovascular risk factors, including smoking

• History of clotting disorder

• Other neurological symptoms

• History of cardiac arrhythmia

• Anticoagulation therapy

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Examination ndings

• Usually normal ocular examination ndings:

fundoscopy may reveal small emboli at the

bifurcations of retinal arterioles

• Visual eld assessment, (e.g. may have a visual

eld defect)

• Extraocular movements

• Pupil examination should be normal

• Neurological examination

Investigations

• Assessment of cardiovascular risk factors and

guided by a neurologist

• Blood count, electrolytes, lipids and fasting

blood glucose

• Investigation for thrombophilia and

hypercoagulable state: discuss with

haematology (consider if age <50 or

relevant history)

• Echocardiogram

• Carotid doppler studies

Important differentials

• GCA

• Vasculitis

• Transient visual obscuration

• Transient blurring of vision: dry eye and

vitreous oaters

Initial treatment

• Liaise with physicians

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving and monocular/binocular

; Past ocular/medical history

; Visual acuity

; Visual elds (by confrontation)

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination

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Visual pathway lesion

Visual pathway pathology

Patients can present with visual complaints

secondary to non-ocular causes. A thorough

history and neurological assessment should be

performed to consider neuroimaging.

Examples of visual pathway pathologies include:

• Optic neuritis

• Traumatic optic neuropathy

• Giant cell arteritis (GCA)

• Non-arteritic ischaemic optic neuropathy

• Chiasmal lesion

• Pituitary tumour or disease

• Bitemporal hemianopia

Cortical blindness

• Lesions affecting the occipital lobe or other

parts of visual pathway

• Diagnoses of exclusion are necessary and

require a formal ophthalmology assessment

Amblyopia

Amblyopia, or reduced visual acuity, results from

deprivation of optimal visual experience during

early childhood. Patients are usually aware of a

history of amblyopia or ‘lazy eye’.

Functional visual loss

Functional vision loss is a decrease in visual acuity

that cannot be accounted for by anatomical or

physiological ndings. The objective assessments

should demonstrate a visual acuity better than

subjective visual acuity.

Vitreous haemorrhage

Seek an urgent referral to an

ophthalmologist<24hrs.

• Flashes

• Floaters with reduced vision

• Presence of RAPD

• Diabetes

• Age-related macular degeneration

(ARMD)

• History of trauma

Figure 49. Slit lamp photograph shows retinal

detachment with visible vitreous.

History ndings

• Sudden loss of vision or ashes/oaters

• May be on anticoagulants

• History of trauma or diabetes

Examination ndings

• Reduced visual acuity: check for RAPD (if

developed retinal complications)

• Anterior vitreous red blood cells (visible on slit

lamp examination)

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Investigations

• Diabetic work up

• Trauma work up (if applicable)

Important differentials

• Retinal detachment

• Retinal tear

• Posterior vitreous detachment

• Proliferative diabetic retinopathy

Initial treatment

• Discussion with ophthalmologist

Section communication checklist

Consider the following:

; Presenting complaint: timing, worsening/

improving or monocular/binocular

; Past ocular/medical history

; Visual acuity (with pinhole if not 6/6)

; Visual elds by confrontation

; Pupil examination: anisocoria and RAPD

; Red reex

; Dilated retinal examination

Acute red eye

or eyelid

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Acute red eye or eyelid

Acute red eye overview

Many conditions can lead to a patient presenting

with a red eye. Many of these are self-limiting or

will respond to simple treatment.

Figure 50. Acute red eye.

Indicators of more serious pathology

• Pain (as opposed to irritation) and/or

reduced vision

• Contact lens use

• Foreign body exposure history (in particular any

possibility of penetrating injury)

• Known connective tissue disorders, e.g. risk of

keratitis, iritis/uveitis, epi/scleritis and giant cell

arteritis (GCA)

Indicators of less serious pathology

• Bilateral red eye, especially in the context of

other viral or allergic symptoms (and in the

absence of any of the above indicators)

Additional useful distinctions

Assess pain relief after topical anaesthetic drop. If

total, this suggests conjunctival irritation or if only

partial, consider the ocular disease process.

The presence of corneal epithelial damage

(uorescein uptake) or any loss of corneal clarity.

Conditions are grouped below as disorders,

primarily of:

• eyelid and associated structures

• conjunctiva and cornea

• anterior chamber

• globe and orbit

Urgency

Triage urgency is guided by the Department of

Health’s Summary of ophthalmic emergency

predictors (OEP) for the Australasian Triage Scale.

The urgency of ophthalmology review following ED

assessment is indicated where relevant.

It is rare for a painless red eye to require an urgent

ophthalmological assessment, particularly if vision

is normal.

Beware of making the diagnosis of

monocular conjunctivitis until more serious

eye disease is excluded.

Conjunctival redness can be diffuse or localised.

Use uorescein to ascertain the nature of any

epithelial defect.

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Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal, i.e.

deep, presence of anterior chamber cells,

blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Acute angle closure crisis

Figure 51. Acute angle crisis, with cloudy cornea,

loss of iris detail, and a xed mid-dilated pupil.

History ndings

• Ocular symptoms include eye ache/pain, cloudy/

loss of vision and red eye

• Systemic symptoms include headache, nausea

and vomiting

Examination ndings

Consider the following:

• The cornea usually has a hazy appearance. The

iris details may be difcult to see due to

corneal oedema.

• The anterior chamber is shallow. Use a ne slit

at 45° on the slit lamp, or shine a torch from the

side for irregular semi-dilated pupils.

• The affected eye is very tender and tense

to palpation.

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Initial treatment

• May require anti-glaucoma drops (see ocular

drug section) and an urgent laser procedure

Notes

Digital palpation tonometry can be

performed. Using both index ngers to

‘ballot’ the eyeball under gently-closed

eyelids, it is possible to compare the

‘hardness’ of the eyeball from one eye to the

other. If the affected eye has elevated

intraocular pressure, then it will feel very

hard and rm to palpation (more like a golf

ball than a gelatinous ball).

Specic communication checklist

Consider the following:

; Symptoms are often triggered by dark

lighting conditions

; Has the patient had cataract surgery

before? If so, then it is extremely unlikely to

be angle closure crisis

; How rm the globe feels on palpation

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal, i.e.

deep, presence of anterior chamber cells,

blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Acute blepharitis

Figure 52. Blepharitis.

History ndings

• Foreign body sensation, tearing and crusting

around the eyes and worse in the morning

• Dry eye symptoms with reading and other tasks

and in air-conditioning

Examination ndings

• Crusty, red and thickened eyelid margin

• Closer inspection may reveal ne telangiectatic

vessels at the lid margin and blocked

Meibomian glands

Initial treatment

Consider the following:

• Treat with daily eyelid hygiene and lubrication as

required. Instructions for bathing the eyelids are

available here.

• Treat with antibiotic ointment if indicated, at

night, for 1 month.

• Ophthalmology referral is normally only

indicated if associated ocular damage,

(e.g. from rubbing or trichiasis).

Notes

• Acute blepharitis may be associated with

marginal keratitis, chalazion or dry eyes.

• Blepharitis is localised eyelid margin

inammation, usually with minimal

ocular involvement.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal, i.e.

deep, presence of anterior chamber cells,

blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Allergic conjunctivitis

Figure 53. Allergic conjunctivitis.

Figure 54. Vernal keratoconjunctivitis:

giant papillae of the upper tarsal conjunctiva.

History ndings

• Itchiness is the hallmark symptom

• Watery, red eyes may be a symptom

• Atopic history (asthma, eczema, allergic rhinitis

and conjunctivitis) and these are often

exacerbated together

Initial treatment

• Cool compresses as required

• Ocular lubricating drops, gels or ointments

(preservative free) qid available over the counter

• Consider systemic antihistamine or topical

antihistamine/mast-cell stabiliser

Notes

Allergic conjunctivitis may be severe and

long-standing, and occasionally results in

corneal ulcers and scarring.

If symptoms are not adequately treated with

the above treatment, consider a non-urgent

referral to an ophthalmologist.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

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Iritis (anterior uveitis or an

anterior chamber inammation)

Figure 55. Anterior uveitis.

History ndings

• Red eye

• Pain (usually a deep ache)

• Photophobia

• Timing of onset of symptoms

• If recent intraocular surgery, (e.g. cataract or

injections), consider endophthalmitis

• History of autoimmune disease,

e.g. vasculitis or rheumatoid arthritis

Figure 56. Slit lamp photograph of hypopyon uveitis.

Examination ndings

Consider the following:

• Visual acuity may be decreased.

• The eye will often appear diffusely red, although

often more marked near the limbus.

• The pupil may be smaller than the contralateral

pupil, due to iris spasm. It may be irregular and

unreactive to light due to adhesions.

• The anterior chamber may appear cloudy from

suspended white blood cells and are. Look

closely for a hypopyon. Assess the cornea for

white cell inltrates (small white opacities

indicating bacterial infection).

• Check for uorescein staining.

• Check intraocular pressure.

Important differentials

• Endophthalmitis

• Uveitis (iritis)

• Severe corneal inammation from bacterial or

viral infection, or chemical burn

• Intraocular foreign body

Initial treatment

Consider the following:

• It is important to differentiate between the

possible diagnoses to determine the urgency of

referral. Endophthalmitis requires immediate

phone referral, as do most corneal conditions.

• Iritis can be a difcult diagnosis to make, so it is

best to refer early.

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Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Specic communication checklist

Consider the following:

; Recent intraocular surgery,

(e.g. cataract, injections)

; History of autoimmune disease

; Contralateral symptoms or a purely

unilateral process

; Visual acuity

; Presence of hypopyon

; Anterior chamber cells can be seen on

slit lamp

; Cornea appears normal

Bacterial or acanthamoebal ulcer

Seek an urgent referral to an ophthalmologist.

Seek an immediate consultation by phone.

May require admission for

microbiological investigation and

intensive antibiotic treatment.

Figure 57. Bacterial ulcer.

History ndings

• Often a history of contact lens wear

Specic communication checklist

Consider the following:

; History of contact lens wear and poor

lens hygiene

Notes

• Epithelial defect with an opacied base

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Bacterial conjunctivitis

Referral is required if:

• vision is affected

• the condition does not improve with treatment

after 2 days, or worsens

• the condition persists after 5 days of treatment.

Ophthalmia neonatorum, dened as conjunctivitis

within the rst 30 days of life, requires immediate

specialist input and treatment. It should be

considered a separate entity from the bacterial

conjunctivitis that affects older children and adults.

Figure 58. Bacterial conjunctivitis. Tender

inamed conjunctiva with purulent discharge

from the conjunctival sac.

History ndings

Consider the following:

• Bacterial conjunctivitis features no corneal or

anterior chamber involvement unless

gonococcal conjunctivitis is suspected.

• It is essential to administer uorescein to

exclude corneal ulcers.

• A patient with bacterial conjunctivitis presents

systemically well. The condition is common in

the elderly and children.

Initial treatment

• Regular hygiene to minimise secretion buildup

• Wash hands and use separate tissues to avoid

infection of the other eye or other people

• Topical antibiotics qid for 5 days

Notes

Non-gonococcal bacterial conjunctivitis

presents with bulbar conjunctival injection

and purulent or mucopurulent discharge.

Gonococcal bacterial conjunctivitis has

marked bulbar conjunctival and periocular

erythema and oedema.

It is important to exclude corneal inltrate or

ulcers that can lead to a sight-threatening

perforation, usually superiorly.

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Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Chalazion/stye

A chalazion swelling is due to a blocked sebaceous

gland. The lid margin is not involved unless a

secondary infection occurs.

A stye is an acute bacterial infection close to/

involving the lid margin. It is associated with lash

follicles and is painful.

Figure 59. Chalazion as seen from the tarsal

conjunctival side.

Figure 60. Chalazion in the upper eyelid, seen

from the skin side.

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Figure 61. Stye in the upper eyelid, at the outer

canthus.

Initial treatment

Consider the following:

• Eyelid hygiene: the eyelid lump will often

disappear after several months of eyelid

hygiene. If bothersome, it may instead be incised

by an ophthalmologist.

• If acutely inamed with surrounding eyelid

inammation, treat as for preseptal cellulitis

with oral antibiotics (dosage as per preseptal

cellulitis) and warm compresses (twice daily)

and ensure ophthalmology follow-up.

Important differentials

Other eyelid lumps, including squamous cell

carcinoma or basal cell carcinoma.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Corneal or conjunctival

foreignbody/corneal abrasion

Consider the following:

• Exclude a penetrating eye injury.

• Any foreign body penetration of the

cornea or retained foreign body

requires an urgent referral to an

ophthalmologist for immediate

consultation by phone.

• Discuss with senior staff if the

foreign body is centrally located on

the cornea (over the visual axis).

History ndings

Consider:

• what material the foreign body likely consists of,

e.g. dirt, glass, metal or organic

• the mechanism of impact (hitting metal on metal

is highly likely to cause a penetrating injury,

whereas grinding or welding rarely do so).

Figure 62. A small piece of iron has lodged in the

corneal periphery. Some rust can already be seen.

Examination ndings

1. Visual acuity: if not 6/6 then check with

a pinhole.

2. Slit lamp: assess for the size, site/s and nature

of foreign body and the depth of penetration.

3. Examine the cornea, anterior chamber, iris,

pupil and lens for any distortion that may

indicate ocular penetration and require urgent

referral to an ophthalmologist.

4. Evert the eyelids to exclude retained subtarsal

foreign bodies and remove them if appropriate.

5. Use uorescein to exclude Seidel-positive

corneal perforation and measure the size of the

epithelial defect.

Important differentials

Penetrating eye injury: partial thickness corneal

lacerations or full thickness corneal perforations.

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Initial treatment

Instruments

• Gloves

• Cotton bud (see Figure 63)

• 21–25g needle (see Figure 65)

• Optional: motorised dental burr (see Figure 64)

Bend the needle tip to 45° from the shaft. Use the

bevelled surface of the instrument angled away

from the patient’s eye. The patient’s forehead

should rest against the slit lamp (see Figure 66).

A motorised dental burr is ONLY for use outside

the central 5mm of the cornea. Always obtain

supervision if you are unfamiliar with

the procedure.

Figure 63. Eye drops, cotton bud and 21-25g

needle.

Figure 64. Motorised dental burr.

Procedure

1. Apply topical anaesthetic agents such as

Amethocaine 1%. Repeat every 30 seconds until

no further discomfort on instillation.

2. Position the patient at slit lamp. Strap or hold

the patient’s head with the help of a colleague

and ask the patient to focus on your ear.

3. Focus the slit lamp.

4. Use an oblique approach tangential to the

cornea. This is very important to reduce the risk

of corneal perforation (see Figure 65 and

Figure 66).

5. Angling a narrow slit beam to 45° can help

identify the depth of the foreign body and

ensure the safety of further removal attempts.

Figure 65. 25G needle angled away from

thepatient.

Figure 66. Corneal foreign body removal with

25Gneedle.

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After removal

Consider the following:

• Use topical antibiotic (qid) and a cycloplegic

agent, (e.g. cyclopentolate 1% bd) for comfort.

Drops are often preferred and are equally as

effective as an ointment in healing a corneal

wound. Administer oral analgesia as required.

• It is not necessary to pad an eye. The

advantage of not padding is that the patient

can see with both eyes.

• The continued use of anaesthetic drops

is contraindicated.

• Assess daily visual acuity and slit lamp review

until complete healing of the defect. The

defect should be measured (see the section on

slit lamp examination) and compared with

previous ndings.

Specic communication checklist

Consider the following:

; Mechanism and likely type of foreign body

; Location of the foreign body on the cornea

; Presence of a residual foreign body or

rust ring

Notes

• Visual acuity may be reduced in a simple

corneal foreign body due to patient

discomfort or refractive errors. Administer

topical local anaesthetic, (e.g. Amethocaine),

darken the room and repeat using a pinhole.

• Retained organic material may lead to

infection; retained metallic foreign bodies may

lead to the formation of rust rings that produce

scarring and corneal epithelial defects.

• Rust rings in the visual axis should be

removed by an ophthalmologist or suitably

experienced emergency physician.

• Protective eyewear is useful but does not

exclude an open globe injury.

Figure 67. Corneal foreign body (macro).

Figure 68. Corneal foreign body (micro). A small

piece of iron has lodged near the margin of the

cornea. Some rust can already be seen.

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Ectropion

Ectropion is a lower eyelid turning outwards with

exposure of the tarsal conjunctiva. It is usually

age-related but may be caused by Bell’s palsy or

contracting scars on the skin of the lower eyelid

and cheek.

Figure 69. Ectropion.

Examination ndings

Consider the following:

• The lower eyelid is loose and can easily be

pulled millimetres from the globe. The tarsal

conjunctiva faces outward and often appears

red due to chronic exposure.

• The eye itself is white. Slit lamp examination

with uorescein may reveal some inferior

punctate erosions due to chronic exposure of

the inferior cornea and conjunctiva.

• The visual acuity is usually normal.

Initial treatment

• Topical lubrication, including night-time ointment

• Refer to an ophthalmologist for non-urgent

surgical management

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Entropion

Figure 70. Entropion.

Figure 71. Corneal abrasion.

History ndings

• Ocular irritation, foreign body sensation

or tearing

Examination ndings

Check the condition of the cornea with a slit lamp

and under blue light with uorescein:

• an intact cornea requires lubrication with a non-

urgent referral

• a corneal ulcer requires taping back the eyelid

away from the cornea, management as for a

corneal foreign body and an ophthalmology

follow-up

• a corneal infection (corneal white opacity and

ulcer) requires urgent referral to

an ophthalmologist.

Notes

Entropion may be age-related, or due to

conjunctival scarring from previous chemical

injury, trauma, surgery or systemic conditions

such as Stevens-Johnson syndrome. Surgery

may be required to reposition the eyelid.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Episcleritis

Episcleritis is the inammation of the connective

tissue overlying the sclera.

History ndings

• Acute onset redness and discomfort, usually

focal

• May be unilateral or bilateral

• Vision is unaffected

Important differentials

Consider the following:

• Scleritis: pain wakes the patient from sleep and

the globe is tender to gentle pressure through

the closed eyelid

• Conjunctivitis: redness tends to be more

generalised and the tarsal conjunctiva (evert the

lower eyelid) is involved

• Pterygium (when inamed): raised nasal

pterygium, with localised redness, possibly with

some punctate conjunctival staining

with uorescein

Figure 72. Episcleritis of the eyeball.

Initial treatment

• Try frequent (hourly) preservative-free

lubricating drops or gels/ointments

• Minimise exposure to sun, wind

and air-conditioning

• Oral NSAIDs may be helpful

• Non-urgent referral to an ophthalmologist if

recurrent or concerns regarding

possible scleritis

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Eyelid lesion

Figure 73. Lesion of left lower eyelid.

Initial treatment

Provided there is no overt eyelid infection/

inammation and no ocular involvement, non-

urgent referral is required. Consider

topical antibiotics.

Herpes simplex virus keratitis

(HSV/HSK)

• Herpetic blepharoconjunctivitis

• Ophthalmia neonatorum

Figure 74. Herpes simplex keratitis.

Figure 75. Herpes simplex keratitis

dendritic ulcer with terminal bulbs.

Figure 76. Herpes simplex keratitis

with steroid complication.

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History ndings

• Unilateral red eye

• Mild blurring of vision

• May have a history of similar episodes in the

same eye or of cold sores

• Ask about possible systemic

immunosuppression

• Topical steroid use will signicantly worsen

this condition

Examination ndings

Consider the following:

• Use uorescein to ascertain the nature of any

epithelial defect.

• Check for dendritic ulcer/s, which are

usually unilateral.

• Multiple previous episodes may have also led

to cornea stromal scarring and

decreased vision.

• A dendritic ulcer (affecting the corneal

epithelium) may also be complicated by

inammation of the deeper corneal layers,

which, if left untreated, can sometimes lead

to perforation. Look for corneal opacication,

loss of iris detail through a cloudy cornea and

reduced vision.

Initial treatment

• Treat with topical acyclovir

• Avoid topical steroid

• Refer to an ophthalmologist within 1–2 days

Specic communication checklist

Consider the following:

; History of cold sores

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or diffuse/

involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber cells,

blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Notes

• Stain with uorescein as the cornea may

develop microdendrites or ulceration.

• Atopic patients will often have more

severe disease.

• Children may develop blepharoconjunctivitis

in primary herpes simplex infection. It may be

bilateral or unilateral, with periocular

vesicles or conjunctivitis.

• Herpes simplex virus keratitis may also be

associated with eczema in children.

• Children will often require admission and

systemic antivirals.

• See the section on ophthalmia neonatorum if

HSV ocular disease in the rst month of life

is suspected.

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Herpes zoster ophthalmicus

(HZO)/shingles

Seek an urgent referral to an ophthalmologist.

Contact an ophthalmologist on the same day if

ocularinvolvement is suspected.

Figure 77. Herpes zoster.

Figure 78. Erythema, oedema, vesiculobullous

eruptions and crusted erosions were present on the

right side of the forehead and yellowish lacrimation

was noted from the right orbital area in the rst

image. Second image shows improvement after 7

days of treatment. Note the vesicles and crusts on

the top and side of the nose (Hutchinson’s sign).

Herpes zoster ophthalmicus is shingles affecting

the ophthalmic branch of the trigeminal nerve

(V1). It may or may not involve the eye, which also

has sensory innervation from V1.

History ndings

• Unilateral vesicles over the forehead, scalp

and eyelid

• Often associated with severe pain

• Ask about systemic immunosuppression,

(e.g. drugs, HIV and cancer)

Examination ndings

Consider the following:

• Check visual acuity, extraocular movements,

intraocular pressure and pupils, including

checking for relative afferent pupillary

defect (RAPD).

• A general inspection will reveal a vesicular

rash, which is usually unilateral and does not

cross the midline. Lesions will crust after a

few days.

• Ocular ndings may include blepharitis (lid

vesicle and redness), conjunctivitis, corneal

ulcers (pseudodendrites), viral keratitis

(corneal opacities or clouding and oedema),

signs of iritis, retinitis and optic disc swelling.

Initial treatment

Oral antivirals should ideally be commenced

within 72 hours of the appearance of the rash.

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Notes

• If the tip of the nose is involved

(Hutchinson’s sign), there is a higher risk

of ocular involvement.

• Always suspect ocular involvement if the

eye is red, vision is reduced or uorescein

staining is present.

• Ocular involvement should prompt

ophthalmic referral within 24 hours, or

earlier if the vision is affected or there are

abnormalities on fundoscopy.

Section communication checklist

Consider the following:

; History of cold sores often exists

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some contralateral

symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Hyphaema

Seek urgent ophthalmology referral and immediate

consultation by phone.

Hyphaema is the presence of blood in the anterior

chamber. It may present as a ne suspension of red

blood cells in aqueous (micro-hyphaema) or as a

blood-aqueous uid level (macro-hyphaema) as

shown in Figure 79 and Figure 80).

Figure 79. Hyphaema.

Figure 80. A 2mm macro-hyphaema, as measured

from the inferior limbus. Note the pupil is dilated

inferiorly. This may signify a focal traumatic

mydriasis, which is often present in a blunt (closed-

eye) injury.

Photograph courtesy of Lawrence B. Stack, MD, Professor of

Emergency Medicine and Paediatrics, Vanderbilt University Medical

Center, Nashville, Tennessee, USA.

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History ndings

• Usually trauma-related

• Consider non-accidental injury in children and

blood dyscrasias

Examination ndings

• Check visual acuity and pupils

• Check intraocular pressure as this is often

acutely elevated

• Check for other evidence of blunt eye injury and

orbital fracture

Initial treatment

• Protect the eye with a shield

• Avoid pressure on the eye

• Bed rest

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal,

i.e. cloudy, opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Notes

• Permanent vision loss may be caused by

elevated intraocular pressure, cornea blood

staining with prolonged hyphaemia and

associated ocular blunt eye injuries,

(e.g. retinal detachment).

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Hypopyon

Seek urgent ophthalmology referral and immediate

consultation by phone.

Hypopyon is the presence of pus in the anterior

chamber. It is a sinister sign and is usually

associated with orid intraocular infection

(endophthalmitis), requiring immediate referral to

an ophthalmologist.

Figure 81. Hypopyon with a visible accumulation

of white cells inferiorly seen in severe uveitis.

History ndings

• History of intraocular injection, cataract,

glaucoma or other ocular surgery

• History of eye trauma, intraocular foreign body

or contact lens wear

• Pain, redness or blurring/loss of vision

• Current eyedrops used

Examination ndings

• Visual acuity and pupils

• Slit lamp examination looking for a leaking open

wound (Seidel’s test)

• Check intraocular pressure

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some contralateral

symptoms

; Best (pinhole) visual acuity of each eye

; Eyelid involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Specic communication checklist

Consider the following:

; Recent ocular surgery or trauma

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Notes

Hypopyon is a sign that there is severe anterior

chamber inammation. This may be due to

endophthalmitis, a severe corneal infection, or

orid uveitis. It should be urgently managed as

endophthalmitis until proven otherwise.

Intravitreal injection (for macular

degeneration) or cataract surgery in the past

1–2 weeks accounts for most cases

of endophthalmitis.

Treatment is immediate intravitreal antibiotics

administered by the ophthalmologist. Failure

to institute prompt treatment often leads to

permanent loss of vision or the eye.

Marginal keratitis

Seek immediate referral to an ophthalmologist.

Figure 82. Marginal keratitis.

Figure 83. Slit lamp photograph of the right eye

with marginal keratitis between 12 o’clock to 2

o’clock positions along with a pannus.

Notes

Marginal keratitis:

• is secondary to blepharitis

• features ulcers situated at the

corneal periphery

• requires discussion with an ophthalmologist.

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Neovascular glaucoma

Seek an urgent referral to an ophthalmologist (<24hr).

Neovascular glaucoma is a type of glaucoma that is

caused by vascular injury to the eye, including

diabetic retinopathy, central retinal vein occlusion,

central retinal artery occlusion and ocular

ischaemic syndrome. The intraocular pressure is

often >35mmHg, and it is a difcult condition

to treat.

Poor vision and high intraocular pressure

(cloudy cornea, nausea or vomiting).

Figure 84. Tufts of neovascularisation at the

peripupillary margin.

History ndings

Pain, red eye, photophobia and reduced vision. May

have a history of sudden and persistent visual loss

and/or multiple cardiovascular risk factors.

Examination ndings

• Vision may be reduced due to the underlying

cause of ocular ischaemia

• Iris neovascularisation and conjunctival erythema

• Cloudy cornea if intraocular pressure is raised

• Pupils may be xed, dilated or show an RAPD

• Fundus examination may show retinal pathology

resulting in ischaemia, e.g. diabetic retinopathy

or central retinal vein occlusion (CRVO)

Investigations

• Cardiovascular risk factor work up

Important differentials

• Acute angle closure or uveitic glaucoma

Initial treatment

• Consult the ophthalmology team to establish a

diagnosis and underlying cause

• Address cardiovascular risk factors

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Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Specic communication checklist

Consider the following:

; Medical history and ocular history

; Cardiovascular risk factors

; Visual acuity, pupil assessment, anterior

segment ndings and intraocular pressure

if able to obtain

Ophthalmia neonatorum

(neonatal conjunctivitis)

Seek an urgent referral to an ophthalmologist,

paediatrician and infectious diseases specialist.

This condition often requires admission to

hospital for investigation and treatment.

Ophthalmia neonatorum is an acute purulent

conjunctival infection in the rst weeks of life.

Organisms of concern include Neisseria

gonorrhoeae (N.gonorrhoeae) (especially within

the rst 5 days), Chlamydia trachomatis (C.

trachomatis) (up to 60 days) or HSV. Scarring or

perforation can occur and any signs of

gonococcal sepsis should be elicited. Gonococcal

ophthalmia presents with orid swelling.

Chlamydial ophthalmia usually presents with

milder chemosis. HSV is seen within 2 weeks after

birth and may have typical vesicles on the eyelid

margin. Exclude corneal dendrite with

uorescein staining.

Ophthalmia neonatorum is a serious

infection due to the lack of immunity in

the neonate. Systemic complications

include meningitis, sepsis, arthritis

and pneumonia.

Sight-threatening ocular complications

include corneal ulcer and perforation.

History ndings

• Previous or current sexually transmitted

maternal infection

• Vaginal delivery

• Occurs in the rst month of life

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Examination ndings

• Bilateral mucopurulent discharge typically

• Red eyes and diffuse conjunctival injection

• Perform uorescein staining to exclude corneal

ulcers or dendrites

Figure 85. Newborn with gonococcal ophthalmia

neonatorum caused by a maternally transmitted

gonococcal infection.

Investigations

• Swab for urgent microscopy and culture

• Consider blood cultures to exclude sepsis or

gonococcal infection concerns

Important differentials

Consider the following:

• Dacryocystitis presents with swelling and

erythema just below the inner canthus, but the

eye appears white.

• Nasolacrimal duct obstruction involves high

tear lm and reux of mucopurulent material

from the punctum when pressure is applied

over the lacrimal sac. The eye is white. Symptoms

usually appear in the rst 1–2 months of life.

Initial treatment

• Urgent systemic and topical antibiotic treatment

• Referral to a sexual health clinic for treatment of

parents and contact tracing

Specic communication checklist

Consider the following:

; Ask parents about sexually transmitted

infections

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some contralateral

symptoms

; Best (pinhole) visual acuity of each eye

; Eyelid involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

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Notes

Consider the following:

• As a notiable disease, parents must be

investigated and treated. Seek a referral to

a sexual health clinic.

• Causes include gonorrhoea, chlamydia or

HSV infections.

• A gonorrhoeal infection is usually seen

within 3–4 days after birth, with severe

chemosis and copious discharge. Urgent

systemic treatment is required, as delays

may lead to corneal perforation.

• Chlamydia is the most common causative

infection and is usually seen within the rst

week after birth with mild swelling and

chemosis.

• HSV is seen within 2 weeks after birth and

may present as typical vesicles on the

eyelid margin. Exclude corneal dendrite

with uorescein staining.

Preseptal cellulitis

(periorbital cellulitis)

Seek an urgent referral to an ophthalmologist

(<24 hours).

Figure 86. Periorbital cellulitis in a 20-year-old

man.

History ndings

• Trivial trauma may precede cellulitis, including

an insect bite, chalazion or skin trauma

Examination ndings

• Check for proptosis (should be absent but do not

confuse with lid swelling) and extraocular

movements (should be normal)

• Visual acuity and optic nerve function testing

should be normal

• The eye should appear white

• Usually features unilateral eyelid erythema,

tenderness and warmth

• Usually features minimal conjunctival injection

and no pain with eye movements

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Important differentials

Consider the following:

• Orbital cellulitis: optic nerve function and

vision may be affected, as well as ocular

motility. Proptosis and painful eye movements

may also occur.

• Chalazion: a blocked Meibomian gland may

initially present with diffuse inammation of

the preseptal tissues. This often cannot be

differentiated from preseptal cellulitis

clinically and should therefore be treated as

such. Within a few days, however, a distinct

eyelid lump can be felt and seen, pointing to

the diagnosis of chalazion.

Initial treatment

If the eye is unable to be visualised, or the child is

febrile or unwell or less than 2 years old, then

they must be urgently referred to exclude and

treat possible orbital cellulitis.

Children older than 2 years with non-severe

preseptal infection, who are afebrile and

systemically well, may be treated with broad-

spectrum oral antibiotics and daily review.

Seek a same day referral by phone to

the ophthalmologist.

Section communication checklist

Consider the following:

Specic communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

; History of recent viral URTI or

sinus infection

; Ask for a history of recent skin infection

or trauma

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Pterygium

Figure 87. Right nasal pterygium. The eye is

looking to the right.

Pterygium is a raised, yellowish eshy lesion at the

limbus that may become painful and red if inamed.

It is usually on the nasal side and is often bilateral.

History ndings

Consider the following:

• A white lesion, often there for many years, which

occasionally becomes red and painful, particularly

following prolonged exposure to dry air and wind,

(e.g. long plane ights or air-conditioning). Once

inamed, it may require several days to settle.

• Check for a history of sun exposure or an

outdoor occupation.

Figure 88. Anterior segment image of pterygium

case. The surface vascularity is scored as +++.

Examination ndings

Consider the following:

• Visual acuity may be decreased, but not

acutely, as the presence of the pterygium can

cause optical distortion (astigmatism). This can

be somewhat corrected with glasses or a

pinhole on testing.

• There may be mild punctate staining on

uorescein testing over the pterygium or

adjacent cornea.

Important differentials

• Conjunctival dysplastic lesions look more

eshy, raised and vascular, and are often

rapidly growing

• If in doubt, refer to the ophthalmologist

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Initial treatment

• Lubricating eye drops hourly (preservative-free

drops or gel)

• Wrap-around sunglasses when outdoors

Notes

• Pterygium typically has a long duration and

affects the nasal conjunctivae

more frequently.

• It may be surgically excised by an

ophthalmologist if frequently inamed

or vision-threatening.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Scleritis

Seek an urgent referral to an ophthalmologist

(<24 hours).

Figure 89. Scleritis with scleral thinning and dark

choroidal show.

Figure 90. Inferior scleritis.

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History ndings

• Painful and red eye

• Pain is a ‘deep ache’ and often wakes the patient

from sleep

• Redness, usually unilateral, and may be

localised to the involved area or diffuse

• History of life-threatening vasculitis or

connective tissue disease, especially

rheumatoid arthritis

Examination ndings

• Visual acuity may be reduced

• Globe is tender to palpation through the

closed eyelid

• Sclera is thickened and discoloured

• If the sclera is thinned from ongoing

inammation, there may be a dark discolouration

which is the pigmented choroid showing through

(Figure 89); if there is severe thinning, consider

globe perforation

Important differentials

Consider the following:

• Episcleritis occurs when layers supercial to the

sclera are inamed. This may be autoimmune-

related or exposure-related, (e.g. wind while

cycling or air-conditioning on an aeroplane).

• Conjunctivitis is more diffuse and involves the

tarsal conjunctiva.

Initial treatment

• Consult an ophthalmologist

• Consider vasculitis and autoimmune screen

• May consider systemic NSAIDs and steroids on

consultation with an ophthalmologist

and rheumatologist

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Specic communication checklist

Consider the following:

; Ask about pain waking the patient

from sleep

; Systems review, especially for

autoimmune disease

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Subconjunctival haemorrhage

Figure 91. Subconjunctival haemorrhage of the

temporal bulbar conjunctiva.

Figure 92. Subconjunctival haemorrhage after

one week, extending nasally and temporally.

Figure 93. Four weeks after haemorrhage.

History ndings

Consider the following:

• A subconjunctival haemorrhage is discovered on

waking when looking in the mirror, as it is

otherwise largely asymptomatic.

• It may be associated with mild grittiness or

dryness of the eye if the haemorrhage is raised

and causes adjacent corneal drying.

• It is possibly associated with minor injuries

including eye-rubbing, foreign body

and Valsalva.

• It is common with the use of antiplatelet agents

and anticoagulants.

Examination ndings

• Supercial blood under the conjunctivae

• Unilateral, localised and sharply circumscribed

at the limbus

• Underlying sclera is not visible

• No inammation, pain or discharge

• Vision is unchanged

Important differentials

Consider the following:

• Open-globe injury (penetrating eye injury): a

subconjunctival haemorrhage that is large,

extends posteriorly or with a suspicious history

of penetrating eye injury (involving a sharp

object), ruptured globe (from severe blunt

trauma) or intraocular foreign body should be

examined thoroughly, as the haemorrhage may

mask an underlying scleral wound.

• Examine the visual acuity, pupil shape and

reactions, extraocular movements, anterior

segment on the slit lamp, red reex

and fundoscopy.

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Initial treatment

• Check and manage blood pressure

• For patients on Warfarin, check INR and

manage accordingly

• Use lubricating drops if gritty or dry eye

symptoms present

• Refer to an ophthalmologist if the condition

worsens or pain develops

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Trichiasis

A condition where eyelashes (not eyelids) are

abnormally turned in towards the eye.

History ndings

• Ocular irritation, foreign body sensation

and tearing

Examination ndings

• Inturned eyelashes which may rub on the cornea

with blinking

• Corneal staining close to the lash location

(punctate erosions or a frank corneal ulcer)

Figure 94. An image of the preoperative

eyelashes.

Initial treatment

• Epilate offending lashes

• Lubricate every 2–3 hours using

preservative-free lubricant

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Notes

Consider the following:

• Trichiasis often arises from years of

blepharitis, resulting in a distortion of the

eyelid margin.

• Epilated lashes will often grow back after 6

weeks. More permanent treatment (laser,

freezing or electrolysis of lash follicle) may

be performed by an ophthalmologist.

Ophthalmology referral is indicated if

concerns for cornea, e.g. recurrent abrasions.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelids involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Viral conjunctivitis

Highly contagious. Observe

Standard Precautions.

• NSW Health Epidemic Keratoconjunctivitis

fact sheet

• RANZCO Infection Control Guidelines Fact

Sheet for Epidemic Keratoconjunctivitis (EKC)

• Viral conjunctivitis is most commonly caused by

adenovirus; however, HSV and VZV, (e.g. part of

V1 shingles) should be considered as causes

Figure 95. Viral conjunctivitis.

History ndings

Consider the following:

• Undertake a contact history with person/s

affected with red eye(s) or upper respiratory

tract infection symptoms (especially children).

• Viral conjunctivitis involves a burning sensation

and watery discharge (different from purulent

exudate in bacterial infections).

• It classically begins in one eye with spread to

the other after 3 days.

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Examination ndings

• Unilateral or bilateral red eye with involvement

of the whole conjunctiva, including tarsal

conjunctiva on eyelid eversion (use gloves for

infection control)

• Lid eversion may also reveal follicles (small pale

raised lumps of 0.5–1mm between the

injected vessels)

• Preauricular lymphadenopathy

• Visual acuity is usually mostly normal (6/9

or better)

• Check pupils for anisocoria (consider iritis as a

differential diagnosis if miosis is present)

Initial treatment

Consider the following:

• Limit transmission: perform frequent

handwashing, use separate tissues, avoid

contact with others while infectious (about 10–12

days from onset of symptoms), disinfect

surfaces, (e.g. handles and light switches) and

avoid sharing of towels and pillows.

• Provide symptomatic relief using cool

compresses and preservative-free lubricating

drops, gels or ointments every 1¬2 hours.

• Administer antibiotic drops if ulcers are present

as prophylaxis.

• Avoid steroids.

• Seek a more urgent ophthalmology referral

(within 24 hours) if photophobia occurs and

there is a marked decrease in visual acuity.

Notes

• Resolution may take several weeks.

• If it lasts longer than 3 weeks, consider

other diagnoses, including chlamydia

conjunctivitis and other diagnoses, (e.g.

episcleritis, scleritis, iritis and

HSV keratitis).

• Consider other diagnoses if presented with

a unilateral red eye of >3 days duration.

Section communication checklist

Consider the following:

; Onset and duration of symptoms

; Painful/not painful

; Distribution of redness (localised or

diffuse/involving tarsal conjunctiva)

; Purely unilateral, or some

contralateral symptoms

; Best (pinhole) visual acuity of each eye

; Eyelid involvement (red or swollen)

; Cornea normal or not normal, i.e. cloudy,

opacities or uorescein staining

; Anterior chamber normal or not normal,

i.e. deep, presence of anterior chamber

cells, blood or hypopyon

; Iris normal, i.e. round, equal, reactive pupils

with normal iris detail visible

; Equal red reexes

Treatments

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Treatments

Ocular drugs

For detailed information on ocular drugs, refer to

the Sydney Eye Hospital’s Ophthalmic

Pharmacopoeia App.

Eye drops

Eye drops can get washed out if they are instilled in

quick succession. Therefore, wait at least 5–10

minutes between eye drop instillation for maximum

effect.

Many eye drops are available as commercially

prepared Minims that can look indistinguishable

from each other. Check carefully as you prepare an

eye drop, then double-check immediately

before instillation.

In the rare situation that you need to prepare the

periocular skin prior to a procedure, you can use

dilute Betadine with an equal amount of saline (to

give Betadine 5%) or aqueous chlorhexidine (do

NOT use the chlorhexidine, which comes mixed

with alcohol). A drop of either of these substances

can go into the eye, provided there is a topical

anaesthetic already in place and the eye is irrigated

thoroughly afterwards.

Topical anaesthetic

Topical anaesthetic is used to improve patient

comfort and as an aid to examination. Anaesthetic

effects last between 10 and 20 minutes, so warn

the patient that the relief they feel will be

temporary. Ensure that topical anaesthetic is

instilled before irrigating for chemical injuries.

It is not standard practice to prescribe topical

anaesthetic for patients to take home as its safety

has not been established and it may either cause or

mask the development of complications.

Common anaesthetics include Amethocaine 0.1%

(tetracaine) and benoxinate 0.4%, which are usually

available in commercially prepared Minims. It is

also possible to use drops of lignocaine 1–2%

(preferably without adrenaline), identical to the

subcutaneous preparation.

Using topical anaesthetic to treat

epithelial defects

The regular use of topical anaesthetic to improve

comfort while simple corneal epithelial defects

heal is controversial. Studies have shown that

topical anaesthetic is toxic to corneal epithelial and

stromal cells with prolonged use. Several case

series have not demonstrated any adverse effects;

however, safety has not been adequately

established. At the time of writing the issue

remains unresolved.

If you are considering prescribing topical

anaesthetic to improve a patient’s comfort while an

epithelial defect heals, please remember that

safety has not been established. While corneal

epithelial defects are very painful, they will usually

heal within a few days.

Fluorescein

Fluorescein is used to diagnose corneal epithelial

defects. It is generally available in Minims at 2%

concentration (orange), at 0.2% concentration

combined with lignocaine anaesthetic (yellow) or in

uorescein strips moistened with normal saline,

then touched against the conjunctiva or in the

fornix (NOT the cornea itself).

The optical properties of uorescein are that it

absorbs blue light and reects green light. The

chemical properties of uorescein are that it binds

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to denuded areas of epithelium, and elsewhere is

washed away by the tear lm. This is the basis for

its use: to detect corneal epithelial defects (hence

the importance of using blue light and not green). It

also binds to mucus strands, which can be

differentiated from epithelial defects by their

movement on blinking.

Orange-coloured 2% uorescein does not

uoresce because it is too concentrated. It is used

to detect corneal leaks, which is done by instilling it

at full concentration on the eye and then examining

it under cobalt blue light at the slit lamp. At the

point of the corneal wound, aqueous leaking out

will dilute the uorescein and it will uoresce

(appearing as a green rivulet trickling down through

the orange uorescein in the tear lm). This is

known as a Seidel test, and a leaking wound is

termed ‘Seidel positive’.

For the same reason, if you administer a large drop

of orange 2% uorescein into the eye looking for an

epithelial defect, you will probably not be able to

see one for several minutes, and in that time the

orange uorescein will stain the cornea and leak

into the anterior chamber, rendering further

examination of the anterior chamber more difcult.

The key to using it is to administer a very small drop

into the eye and use the patient’s tear lm to

disperse and dilute it. Also be aware that

uorescein stains contact lenses, skin and clothing

(albeit temporarily), so be careful using it.

Mydriatic drops

Dilating the patient’s pupil allows fundus

examination and is also used in situations of

intraocular inammation to paralyse and enlarge

the pupil. As mentioned elsewhere, it is not

appropriate to dilate a patient’s eyes in the ED

before speaking with an ophthalmologist (or, in

some cases, a neurosurgeon). It usually takes 15 to

20 minutes for the drops to work and vision is

affected for several hours, so patients are not

permitted to drive following dilation.

Commonly available mydriatic drops are

tropicamide 1%, phenylephrine at 2.5% and 10%,

cyclopentolate 1% (or 0.5%) and atropine 1% (one

drop has an effect for 7–10 days), in both Minims

and bottles. Many textbooks will refer to

homatropine, which is a drop that is no longer

manufactured but can generally be replaced

by cyclopentolate.

Topical antibiotics

These are used both as prophylaxis and treatment

for microbial infections and commonly available

preparations include chloramphenicol, ooxacin,

ciprooxacin, gentamicin and tobramycin. Some

are available as drops, others as ointments and

some as both. In certain situations, other antibiotics

can be compounded by pharmacies for use as an

eye drop.

The most common topical antiviral is acyclovir

ointment, which is used for herpetic epithelial

keratitis. This condition requires specialist

ophthalmology management.

Ocular lubricating drops

Lubricating drops are used to treat dry eye, which is

very common. Lubricating drops are generally

available in two forms – preserved (in bottles) and

non-preserved (in Minims, or similar ampoules) –

and can be purchased over the counter from the

chemist. If a patient requires lubricating drops

more than four to six times a day, they should use

non-preserved drops to lower the risk of toxicity

from preservatives. Lubricating gels and ointments

are an alternative. They are effective, longer lasting

and most applicable for nocturnal use but can blur

vision if used during the day.

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Topical steroids

Topical steroids are used to treat ocular surface

and intraocular inammation and should only be

prescribed by an ophthalmologist due to the

substantial risk of complications, including

glaucoma, microbial keratitis and cataracts.

Ocular antihypertensives

(glaucoma drops)

Ocular antihypertensives are used to lower

intraocular pressure in the treatment of glaucoma.

Many patients are on these medications because

glaucoma is such a common disease. There are a

multitude of different drops and drop combinations

across four major drug classes. If required for the

treatment of acutely elevated pressure, refer to

specic advice provided by an ophthalmologist.

Eye pad and shield

It is not wise to pad an eye with minor corneal or

conjunctival trauma. A pad placed inappropriately

may exacerbate injury while the cornea is

anaesthetised, or if the patient is already in pain

due to an existing corneal injury. While a pad may

be placed in specic situations, always discuss it

with an ophthalmologist before doing so. A patient

cannot drive with a pad on one eye as it reduces

depth perception.

It can be tempting to prescribe a topical

anaesthetic to patients with corneal epithelial

defects to improve comfort during healing. Please

be aware that the safety of doing this has not been

established and it remains controversial.

Technique for eye pad

Video - Eye Padding

Figure 96. Single eye pad.

1. Use one or two pads (stacked on top of

each other).

2. Prepare three pieces of tape in advance and

have them on hand.

3. Ask the patient to close their eyes, then place

the pad on rmly so that the eye remains

closed. Tape rmly in place.

4. When applied correctly, the patient’s padded

eye should remain closed when they open the

other eye.

5. The tape should angle away from the mouth. To

ensure that the tape is compact on the eye,

place the pieces parallel to each other.

6. It may help to put chloramphenicol ointment in

the eye prior to applying the pad or use a small

piece of Jelonet between the pad and the

closed eyelid.

Notes

If the eye opens underneath the eye pad, it

may not be noticed by the patient and they can

sustain signicant corneal injury by the time

the pad is removed.

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Technique for an eye shield

1. Use either a clear plastic shield or a truncated

disposable cup.

2. Place it over the eye without putting any

pressure on the orbit. Make sure the rim of the

shield or the cup is resting on the bony

orbital margin.

In situations of globe rupture do NOT put

anything underneath the shield in contact

with the eye as the goal is to avoid any

pressure on the globe whatsoever.

Figure 97. Shield made from a disposable cup.

Figure 98. Disposable cup.

Figure 99. Eye shield.

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How to put in eye drops

Self-instillation

1. Wash hands.

2. Uncap the bottle/tube.

3. Tilt your head up.

4. Use the hand on the opposite side to hold the

bottle resting on the bridge of the nose, taking

care not to touch any surfaces with the

bottle tip.

5. Pull down the lower lid with the ngers of the

same side so that a visible pocket forms in the

space behind the lid.

6. Gently squeeze the bottle to deliver 1 or 2 drops.

7. Shut the eyelid for approximately 1 minute.

8. Wipe away excess drops/ointment from

your face.

9. Re-cap the bottle.

10. Wash hands.

Figure 100. Self-instillation of eye drops.

Assisted instillation

1. Wash hands.

2. Uncap the container or twist off the tab.

3. Pull the lower eyelid gently down with

forenger to form a pocket.

4. Tilt the head slightly back and look up.

5. Hold the bottle gently between the thumb and

forenger and gently squeeze the

recommended number of drops into the

pocket formed.

6. Do not touch the eye with bottle tip.

7. Shut the eye and move the eyeball from side to

side to spread the medication.

8. Wash hands.

Figure 101. Drops administered by a healthcare

worker or family member.

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References

1. Prabhasawat P, Ekpo P, Uiprasertkul M, et al.

Efcacy of cultivated corneal epithelial stem

cells for ocular surface reconstruction. Clin

Ophthalmol. 2012;6:1483-92. DOI: 10.2147/

OPTH.S33951.

2. Choi YJ, Jung MS, Kim SY. Retinal hemorrhage

associated with perinatal distress in newborns.

Korean J Ophthalmol. 2011 Oct;25(5):311-6. DOI:

10.3341/kjo.2011.25.5.311.

3. Zehetner C, Bechrakis NE. White centered

retinal hemorrhages in vitamin b(12) deciency

anemia. Case Rep Ophthalmol. 2011 May;2(2):140-

4. DOI: 10.1159/000328123.

4. Vijaya L, Manish P, Ronnie G, et al. Management

of complications in glaucoma surgery. Indian J

Ophthalmol. 2011 Jan;59 Suppl(Suppl1):S131-40.

DOI: 10.4103/0301-4738.73689.

5. Thompson D, Stanescu C, Pryor P, et al.

Retrobulbar hematoma from warfarin toxicity

and the limitations of bedside ocular sonography.

West J Emerg Med. 2010 May;11(2):208-10.

6. Wang Y, Wang XH, Tian MM, Xie CJ, Liu Y, Pan

QQ, Lu YN, CC BY 4.0, via Wikimedia Commons

(accessed October 2023). Available from:

https://commons.wikimedia.org/wiki/

File:Oculomotor_nerve_palsy.png

7. Mohammad T Masoud, Ajmal Rehman and Yusuf

Shaikh, CC BY 2.0, via Wikimedia Commons

(accessed October 2023). Available from:

https://commons.wikimedia.org/wiki/

File:Abducens_palsy.jpg

8. Russell Neches (Rneches), CC BY-SA 3.0, via

Wikimedia Commons (accessed October 2023).

Available from: https://commons.wikimedia.

org/wiki/File:Central_serous_retinopathy.jpg

9. Jonathan Trobe, M.D., CC BY 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://commons.wikimedia.org/wiki/

File:Acute_Angle_Closure-glaucoma.jpg

10. Cumulus at Dutch Wikipedia, CC BY-SA 3.0, via

Wikimedia Commons (accessed October 2023).

Available from: https://commons.wikimedia.

org/wiki/File:Myasthenia.jpg

11. CDC/Dr. Sellers/Emory University, Public

domain, via Wikimedia Commons (accessed

October 2023). Available from: https://

commons.wikimedia.org/wiki/File:Bilateral_

exophthalmos.jpg

12. National Eye Institute/National Institutes of

Health, Public domain, via Wikimedia Commons

(accessed October 2023). Available from:

https://commons.wikimedia.org/wiki/File:Slit_

lamp_photograph_showing_retinal_

detachment_in_Von_Hippel-Lindau_disease_

EDA08.JPG

13. La Rosa M, Lionetti E, Reibaldi M, et al. Allergic

conjunctivitis: a comprehensive review of the

literature. Ital J Pediatr. 2013 Mar 14;39:18. doi:

10.1186/1824-7288-39-18.

14. Jonathan Trobe, M.D., CC BY 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://creativecommons.org/licenses/

by/3.0

15. London NJ, Garg SJ, Moorthy RS, et al. Drug-

induced uveitis. J Ophthalmic Inamm Infect.

2013 Mar 25;3(1):43. DOI: 10.1186/1869-5760-3-43.

16. Grook Da Oger, CC BY-SA 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://creativecommons.org/licenses/

by-sa/3.0

Eye Emergency Manual December 2023

Agency for Clinical Innovation 132 aci.health.nsw.gov.au

17. E van Herk, CC BY-SA 3.0, E van Herk, CC BY-SA

3.0, via Wikimedia Commons (accessed October

2023). Available from: https://creativecommons.

org/licenses/by-sa/3.0

18. Asagan, CC BY-SA 3.0, via Wikimedia Commons

(accessed October 2023). Available from:

https://creativecommons.org/licenses/by-

sa/3.0

19. Seo KS, Lee HM, Shin HJ, et al. Coinfection with

herpes zoster ophthalmicus and oriental eye

worm in a rural woman: the rst report of an

unusual case. Ann Dermatol. 2014 Feb;26(1):125-

6. DOI: 10.5021/ad.2014.26.1.125.

20. Babu K, Maralihalli RE. Insect wing tarsal

foreign body causing conjunctival granuloma

and marginal keratitis. Indian J Ophthalmol.

2009 Nov-Dec;57(6):473-4.

DOI: 10.4103/0301-4738.57154.

21. Columbia University Irving Medical Center.

Neovascular glaucoma. New York, USA:

Columbia University; 2023 (accessed October

2023). Available from: https://www.vagelos.

columbia.edu/departments-centers/

ophthalmology/education/digital-reference-

ophthalmology/glaucoma/angle-closure-

glaucoma/neovascular-glaucoma

22. CDC/ J. Pledger, Public domain, via Wikimedia

Commons (accessed October 2023). Available

from: https://commons.wikimedia.org/wiki/

File:Gonococcal_ophthalmia_neonatorum.jpg

23. Afrodriguezg, CC BY-SA 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://commons.wikimedia.org/wiki/

File:Celulitis_Periorbitaria_(Preseptal).JPG

24. Park CY, Choi JS, Lee SJ, et al. Cyclooxygenase-

2-expressing macrophages in human pterygium

co-express vascular endothelial growth factor.

Mol Vis. 2011;17:3468-80.

25. Kamath YS, Rathinam SR, Kawali A. Ocular

toxoplasmosis associated with scleritis. Indian J

Ophthalmol. 2013 Jun;61(6):295-7. DOI:

10.4103/0301-4738.111130.

26. Daniel Flather, CC BY-SA 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://commons.wikimedia.org/wiki/

File:Subconjunctival_hemorrhage_eye.JPG

27. Therealbs 2002, CC BY-SA 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://commons.wikimedia.org/wiki/

File:Subconjunctival_hemorrhage_before_

after_(cropped).jpg

28. Therealbs 2002, CC BY-SA 3.0, via Wikimedia

Commons (accessed October 2023). Available

from: https://commons.wikimedia.org/wiki/

File:Subconjunctival_hemorrhage_before_

after_(cropped4weeks).jpg

29. Kim GN, Yoo WS, Kim SJ, et al. The effect of

0.02% mitomycin C injection into the hair follicle

with radiofrequency ablation in trichiasis

patients. Korean J Ophthalmol. 2014

Feb;28(1):12-8. DOI: 10.3341/kjo.2014.28.1.12.

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PubMed search terms

((("Eye Diseases"[Mesh] OR "Eye Injuries"[Mesh] OR "eye disease*"[Title] OR "eye injur*"[Title]) AND

("Emergency Treatment"[Mesh] OR ("emergenc*"[Title] AND "treat*"[Title])) OR ("ocular emergenc*"[Title] OR

"eye emergenc*"[Title])) AND ("Guideline" [Publication Type] OR "Practice Guideline" [Publication Type] OR

"guideline*"[Title] OR "principle*"[Title] OR "procedure*"[Title] OR "diagnos*"[Title] OR "management"[Title]))

NOT ("COVID"[Title/Abstract]) AND (english[Filter]) AND (2009:2023[pdat])

Google search terms

eye injury OR eye disease OR eye emergency AND guidelines OR management

Inclusion and exclusion criteria

Inclusion Exclusion

• Published in English

• Studies reporting empirical data, including

modelling studies, and systematic review articles

• Published between 2009 and present

• Letters, comments, editorials, study protocols, case

reports or conference abstracts

• Abstract only

• Studies or results related to COVID-19

Bibliography

Appendix: Evidence base

• Al-Dhibi HA, Al-Mahmood AM, Arevalo JF. A

systematic approach to emergencies in uveitis.

Middle East Afr J Ophthalmol. 2014 Jul-

Sep;21(3):251-8. DOI: 10.4103/0974-9233.134687

Biousse V, Nahab F, Newman NJ. Management of

Acute Retinal Ischemia: Follow the Guidelines!

Ophthalmology. 2018 Oct;125(10):1597-607. DOI:

10.1016/j.ophtha.2018.03.054

• Chou HD, Chen KJ, Kang EY, et al. Eye irrigation

as a rst-line treatment and diagnostic method

for emergency department patients who

complain of ocular foreign bodies. Sci Rep. 2021

Dec 3;11(1):23386. DOI: 10.1038/s41598-021-

02989-3

• Cugati S, Varma DD, Chen CS, et al. Treatment

options for central retinal artery occlusion. Curr

Treat Options Neurol. 2013 Feb;15(1):63-77. DOI:

10.1007/s11940-012-0202-9

• Dasgupta B. Concise guidance: diagnosis and

management of giant cell arteritis. Clin Med

(Lond). 2010 Aug;10(4):381-6. DOI: 10.7861/

clinmedicine.10-4-381

• Department of Health and Aged Care. Summary

of ophthalmic emergency predictors (OEP) for

the ATS [Internet]. Australia: Department of

Health and Aged Care; 2013 Jan 21 [cited 2023

July 13]. Available from: https://www1.health.

gov.au/internet/publications/publishing.nsf/

Content/triageqrg~triageqrg-eye.

• Dua HS, Ting DSJ, Al Saadi A, et al. Chemical eye

injury: pathophysiology, assessment and

management. Eye (Lond). 2020 Nov;34(11):2001-

19. DOI: 10.1038/s41433-020-1026-6

• Eslani M, Baradaran-Rai A, Movahedan A, et al.

The ocular surface chemical burns. J Ophthalmol.

2014;2014:196827. DOI: 10.1155/2014/196827

Eye Emergency Manual December 2023

Agency for Clinical Innovation 134 aci.health.nsw.gov.au

• Hayreh SS. Management of ischemic optic

neuropathies. Indian J Ophthalmol. 2011 Mar-

Apr;59(2):123-36. DOI: 10.4103/0301-4738.77024

• Heath Jeffery R, Dobes J, Chen F. Eye injuries:

Understanding ocular trauma. Australian Journal

for General Practitioners. 2022 07/01;51:476-82.

• Hodge C, Lawless M. Ocular emergencies. Aust

Fam Physician. 2008 Jul;37(7):506-9.

• Lindeld D, Das-Bhaumik R. Emergency

department management of penetrating eye

injuries. Int Emerg Nurs. 2009 Jul;17(3):155-60.

DOI: 10.1016/j.ienj.2009.01.003

• Mac Grory B, Schrag M, Biousse V, et al.

Management of Central Retinal Artery

Occlusion: A Scientic Statement From the

American Heart Association. Stroke. 2021

Jun;52(6):e282-e94. DOI: 10.1161/

str.0000000000000366

• Mbonde AA, O'Carroll CB, Dulamea OA, et al.

Current Guidelines on Management of

Amaurosis Fugax and Transient Ischemic

Attacks. Asia Pac J Ophthalmol (Phila). 2022

Mar-Apr 01;11(2):168-76.

DOI: 10.1097/apo.0000000000000511

• Michels TC, Ivan O. Glaucoma: Diagnosis and

Management. Am Fam Physician.

2023 Mar;107(3):253-62.

• Miller SC, Fliotsos MJ, Justin GA, et al. Global

Current Practice Patterns for the Management

of Open Globe Injuries. Am J Ophthalmol. 2022

Feb;234:259-73. DOI: 10.1016/j.ajo.2021.08.003

• Nuzzi R, Buschini E, Actis AG. Ophthalmic

evaluation and management of traumatic

accidents associated with retinal breaks and

detachment: a retrospective study. Eur J

Ophthalmol. 2012 Jul-Aug;22(4):641-6.

DOI: 10.5301/ejo.5000088

• O'Connor PM, Crock CT, Dhillon RS, et al.

Resources for the management of ocular

emergencies in Australia. Emerg Med Australas.

2011 Jun;23(3):331-6.

DOI: 10.1111/j.1742-6723.2011.01411.x

• Optometry Australia. Clinical practice guide for

the diagnosis, treatment and management of

anterior eye conditions [Internet]. Melbourne,

Australia: Optometry Australia; 2018 Apr [cited

2023 Jul 13]. Available from: https://www.

optometry.org.au/wp-content/uploads/

Professional_support/Guidelines/anterior_eye_

clinical_practice_guide__2_.pdf.

• Serrano F, Stack LB, Thurman RJ, et al.

Traumatic eye injuries: management principles

for the prehospital setting. Jems. 2013

Dec;38(12):56-62.

• Sethuraman U, Kamat D. The red eye: evaluation

and management. Clin Pediatr (Phila). 2009

Jul;48(6):588-600. DOI:

10.1177/0009922809333094

• The Royal Children's Hospital Melbourne.

Clinical practice guidelines [Internet]. Melbourne,

Australia: The Royal Children's Hospital

Melbourne; 2022 Oct [cited 2023 July 13]. Available

from: https://www.rch.org.au/clinicalguide/.

• The Royal Victorian Eye and Ear Hospital.

Emergency department clinical practice guidelines

[Internet]. Melbourne, Australia: The Royal Victorian

Eye and Ear Hospital; 2023 [cited 2023 July 13].

Available from: https://eyeandear.org.au/health-

professionals/clinical-practice-guidelines/.

• UpToDate. Approach to diagnosis and initial

treatment of eye injuries in the emergency

department [Internet]. Massachusetts, USA:

UpToDate; 2023 Feb 8 [cited 2023 Jul 18].

Available from: https://www.uptodate.com/

contents/approach-to-diagnosis-and-initial-

treatment-of-eye-injuries-in-the-emergency-

department.

• Varma DD, Cugati S, Lee AW, et al. A review of

central retinal artery occlusion: clinical

presentation and management. Eye (Lond). 2013

Jun;27(6):688-97. DOI: 10.1038/eye.2013.25

• Youn TS, Lavin P, Patrylo M, et al. Current

treatment of central retinal artery occlusion: a

national survey. J Neurol. 2018 Feb;265(2):330-5.

DOI: 10.1007/s00415-017-8702-x

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Glossary

Term Denition

Acute angle closure Acute angle closure glaucoma is caused by a rapid or sudden increase in

intraocular pressure (IOP), the pressure inside the eye. Urgent

ophthalmologist attention is required.

Age-related macular

degeneration (ARMD)

A medical condition that may result in blurred or no vision in the central

eld of vision. ARMD may be asymptomatic initially.

Amblyopia Reduced visual acuity that results from deprivation of optimal visual

experience during early childhood. Patients are usually aware of a history

of amblyopia or ‘lazy eye’.

Amsler grid A tool to detect vision problems resulting from damage to the macular or

optic nerves. The tool can be downloaded via the macular haemorrhage

wARMD page.

Anisocoria Asymmetry in pupil size. The degree of asymmetry can differ in light and

dark conditions, so measure pupil size in both. Anisocoria is a feature of

third cranial nerve palsy (greater difference in dark), Horner syndrome

(greater difference in light) and iris trauma.

Anterior chamber (AC) Anatomy term: the space between the iris and corneal endothelium.

Anterior ischaemic optic

neuropathy (AION)

Optic nerve dysfunction secondary to arterial ischaemia of the prelaminar

optic disc arteriole. Giant cell arteritis (GCA) is the most common cause.

Arteritic anterior ischaemic

optic neuropathy (AAION)

Optic nerve dysfunction secondary to ischaemia of the prelaminar optic

disc arterioles with resulting disc swelling and pallor. Giant cell arteritis

(GCA) is the most common cause.

Australasian Triage Scale

(ATS)

A set of triage categories agreed upon by the Australasian College for

Emergency Medicine (ACEM) for use in Emergency Departments. Category

1: Immediate simultaneous assessment and treatment; Category 2: <10

minutes; Category 3: <30 minutes; Category 4: <60 minutes; Category 5:

<120 minutes.

Avulsion Pathologic condition: tearing or wrenching away of a part, e.g.the optic

nerve from the globe.

Bacterial keratitis A vision-threatening bacterial infection of the cornea that can cause loss

of vision in severe cases. The rate of progression of symptoms is related to

the virulence of the infecting organism. Diagnosis is based on clinical history

and slit lamp examination showing the presence of a corneal inltrate.

Bacterial/

acanthamoebal ulcer

An infective condition of the cornea involving disruption of the epithelial layer

with involvement of the corneal stroma. Caused by Acanthamoeba infection.

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Term Denition

Blepharitis Blepharitis is a common eyelid inammation that is sometimes associated

with a bacterial eye infection.

Bradyarrhythmia A slow heart rate: dened as a heart rate of <60 beats per minute (BPM)

in adults.

Canthus The outer or inner corner of the eye where the upper and lower lids meet.

Carotid-cavernous

sinus stula (CCF)

An abnormal communication between the internal or external carotid

arteries and the cavernous sinus.

Cataract The clouding of a normal lens. The main symptom is blurry vision. Patients

may describe vision as looking through a cloudy window. Refer to an

ophthalmologist if not already under care.

Central nervous system

(CNS)

The retina is brain tissue and is considered part of the central nervous

system (CNS). It is the only part of the CNS that can be visualised non-

invasively. Seek neurology referral.

Central retinal vein

occlusion (CRVO)

A blockage of the main vein in the retina.

Central serous

chorioretinopathy/

retinopathy

A disease in which a serous detachment of the neurosensory retina occurs

over an area of leakage from the choriocapillaris through the retinal

pigment epithelium.

Cerebrovascular accident (CVA) Stroke: reduced blood ow to the brain.

Chalazion A benign, painless bump or nodule inside the upper or lower eyelid.

Chemosis Pathologic condition: oedema of the conjunctiva.

Chiasmal pathology Pathology at the part of the brain where the optic nerves partially cross.

Choroidal rupture A break in the choroid.

Cicatrix Scarring that causes shortening of tissue.

Closed globe injury An eye wall wound that is not full thickness.

Coloboma A congenital eye development defect. It can be either unilateral or bilateral

and can affect a number of different parts of the eye. The detection of a

coloboma does not mean that there is a hole in the eye, but that certain

structures within the eye are not fully formed.

Conjunctivitis Inammation of the conjunctiva. May be infective or not.

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Term Denition

Consensual pupil response Pupil constriction when light is shone in the other eye.

Contusion Injury: a bruise or injury without a break in skin/cover.

Cortical blindness Lesions affecting the occipital lobe or other parts of the posterior

visual pathway.

Counting ngers vision (CF) A level of vision where the patient is just able to repeatedly count how many

ngers are held up 30–300cm in front of them with one eye covered and in

good light. The patient is unable to see any letters on the Snellen chart.

Decompensated phoria When the eye moves outward towards the ear or towards the nose or an

eye moves upward as compared to the other eye. It has a gradual onset.

Diplopia (double vision) Symptom/functional defect: double vision.

Direct pupil response Pupil constriction when light is shone in the eye.

Dry eye Inammation of the conjunctiva and cornea of the eye due to inadequate

tear secretion.

Ecchymosis Pathologic condition: bruising.

Ectropion Eyelid is turned outwards away from the eyeball.

Endophthalmitis An intraocular infection and severe inammation of the anterior and/or

posterior chambers of the eye which can occur following surgery,

intraocular injection and trauma.

Entropion When the eyelid is turned towards the eyeball.

Epidemic keratoconjunctivitis

(EKC)

Viral conjunctivitis. Please see advice from NSW Health Infectious

Diseases web page.

Episcleritis A benign, inammatory disease affecting the episclera.

Erosions Pathologic condition: destruction/eating away/loss of corneal epithelium.

Exposure keratopathy Dryness of the cornea caused by incomplete eyelid closure. Consider

causes such as seventh (7th) cranial nerve palsy and Bell's palsy, eyelid

ectropion or eyelid scars. Other contributing factors include: Sjögren's

syndrome (aqueous tear underproduction), blepharitis (evaporative dry

eye), or neurotropic cornea and ulceration, (e.g. HSV or CNS palsy).

Eyelid hygiene This is an important part of treatment and prevention of blepharitis. Daily

routines involve warmth, massage and cleaning the area.

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Term Denition

Eyelid margin The portion located at the edge of the eyelid.

Flashes Flashes are a form of photopsia, a visual phenomenon referring to the

perception of light in the absence of external light stimuli. Photopsias

generated in the eye result from mechanical stimulation of the retina by

vitreoretinal traction. These can be triggered by eye movement and are

usually in the temporal visual eld.

Fluorescein An orange dye that is used in conjunction with a blue light to detect foreign

bodies in the eye.

Floaters The perception of dark spots caused by opacities in the vitreous that are

secondary to degenerative vitreous changes. Patients may describe

oaters as ‘cobwebs’ and 'ies' that are more evident with uniform light

backgrounds, (e.g. blue sky).

Fornix/fornices Potential space between the ocular surface and the conjunctival space of

the eyelid.

Fourth (4th) cranial

nerve palsy

Causes the inability to depress the eye and classically presents as a

vertical or torsional binocular diplopia. Because the fourth cranial nerve

innervates the superior oblique, which has a less well-dened pattern of

action than the rectus muscles, it can be hard to discern an eye movement

disorder. As it has the longest intracranial course of all the cranial nerves,

the fourth nerve is particularly vulnerable to trauma, but palsy can also be

caused by giant cell arteritis (GCA) or compression by a tumour.

Functional visual loss A decrease in visual acuity that cannot be accounted for by anatomical or

physiological ndings. Objective assessments should demonstrate a visual

acuity better than subjective visual acuity.

Giant cell arteritis (GCA) A systemic vasculitis affecting medium and large vessels and also known

as temporal arteritis. GCA is an eye emergency that commonly presents as

anterior ischaemic optic neuropathy (AION). Symptoms include

polymyalgia rheumatica, new onset headache (often temporal), scalp

tenderness, jaw claudication, tongue claudication, fever and night sweats,

loss of weight, generalised muscle pain and weakness and diplopia or

transient visual loss.

Glaucoma A group of eye diseases in which the neurons of the optic nerve at the back

of the eye are slowly destroyed.

Globe The eyeball.

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Term Denition

Hand movements vision (HM) A level of vision that the patient is just able to repeatedly determine when a

hand is held up 30–100cm in front is moving side to side with one eye

covered and in good light. The patient is unable to count ngers.

Herpes simplex A viral disease caused by the herpes simplex virus.

Herpes zoster This virus commonly affects the ophthalmic branch of the trigeminal nerve

(V1). It is also known as shingles. It may or may not involve the eye, which

also has sensory innervation from V1. Ophthalmic manifestations include

conjunctivitis, scleritis, episcleritis, keratitis iridocyclitis, Argyll Robertson

pupil, glaucoma, retinitis, choroiditis, optic neuritis, optic atrophy,

retrobulbar neuritis, exophthalmos, lid retraction, ptosis and extraocular

muscle palsies.

Heterochromia A difference in iris colour. It can occur due to congenital Horner syndrome,

chronic intraocular inammation or prolonged use of some glaucoma drops.

Horner syndrome Caused by a disruption of the sympathetic nervous system. It can cause

minor upper lid ptosis, anisocoria (affected pupil smaller), less sweating on

the affected side of the face (anhidrosis) and a lighter-coloured pupil on

that side (heterochromia) if long-standing or congenital.

Hyperaemia Clinical sign: increased blood ow. Congestion of conjunctival blood vessels.

Hypopyon A visible collection of inammatory cells in the anterior chamber of the eye.

Ice test Myasthenia gravis (MG) diagnostic test: an ice pack is applied to a droopy

eyelid for 2–5 minutes and then the eyelid is examined for improvement

of ptosis.

Identify, Situation,

Background,Assessment

and Recommendation (ISBAR)

A tool to improve patient safety by standardising communication and the

transfer of critical information.

Idiopathic intracranial

hypertension (IIH)

A neurological disorder that is characterised by increased intracranial

pressure in the absence of a tumour or other disease. Commonly also

called pseudotumour cerebri.

Idiopathic orbital

inammatory disease

An inammation of soft tissue involving any area of the orbit.

Inltrate A corneal inltrate is an aggregate of white blood cells located within the

corneal stroma. It usually suggests active bacterial keratitis. There is often

an overlying corneal ulcer, which stains with uorescein.

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Term Denition

Intermediate/posterior uveitis Uveitis is the inammation of the uvea. Intermediate uveitis (also known as

pars planitis or cyclitis) is the inammation of tissues in the area just

behind the iris and lens of the eye. Posterior uveitis (also known as

choroiditis) refers to inammation of the choroid (back part of the uvea).

Posterior uveitis may affect the retina and/or the optic nerve and may lead

to permanent loss of vision. It is rare.

Intermittent angle closure Intermittent episodes of angle closure glaucoma that resolve between

attacks. Symptoms include headache, eye pain or occasional halos around

lights. Over time, these episodes result in peripheral anterior synechiae

(PAS), which can cause permanent elevation of intraocular pressure (IOP)

(chronic angle closure glaucoma).

Intraocular pressure (IOP) Fluid pressure inside the eye.

Iridoschisis Pathologic condition: splitting of the iris/structural formation of a hole in

the iris.

Iritis Inammation that affects the iris. The iris is a part of the middle layer of

the eye (uvea), so iritis is a type of uveitis, more accurately termed

anterior uveitis.

Ischaemia Pathological condition: localised ischaemia caused by arterial constriction.

Keratitis Infection or inammation of the cornea.

Lacrimal drainage apparatus The system containing the orbital structures for tear production

and drainage.

Lagophthalmos Inability to close the eye. Classically caused by seventh nerve palsy but

can also occur due to traumatic disruption of the eyelids. If severe, it can

lead rapidly (within hours) to corneal exposure, irreversible scarring and

blindness.

Lens dislocation A lens that has moved out of position because some or all of the supporting

ligaments have broken.

Leukocoria A white, rather than red, reex when the retina is illuminated from a

distance. A red reex is normally assessed with a direct ophthalmoscope

shining a light into both eyes from a distance – a reected red glow is

normally observed – but can also be observed from camera ashes. The

life-threatening cause that must urgently be excluded is retinoblastoma, a

cancer of the retina that usually occurs in children.

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Term Denition

Light perception

(PL or LP)

A level of vision where, with one eye completely covered, the patient is

repeatedly able to determine when a very bright light is shone on their eye

from about 10cm away. Ensure there are no auditory cues, (e.g. clicking of

light switches). The patient is unable to see hand movements.

Limbus The corneal limbus is the border between the cornea and the sclera.

Macular pathology,

(e.g.macular haemorrhage)

The macula is the central region of the retina and is situated at the

posterior pole of the eye. It is the part of the retina that produces central

vision. Pathology or disease in this area are varied and include oedema and

macular haemorrhage, both of which can be caused by age-related

macular degeneration and central serous chorioretinopathy. Seek

ophthalmologist referral.

Migraine A primary headache disorder characterised by recurrent headaches that

are moderate to severe and typically unilateral. Migraine is the most

common reason for aura.

Miosis The excessive constriction of the pupil of the eye relative to the amount of

light the pupil receives. Causes can include drugs, (e.g. opioids, nicotine

products, antipsychotics, imidazolines and antiemetics) or disease.

Myasthenia gravis

(MG)

Ocular myasthenia gravis is a form of myasthenia gravis in which the

muscles that move the eyes and control the eyelids are weakened, causing

double vision and/or drooping eyelids. Symptoms tend to be worse at the

end of the day.

Mydriasis The dilation of the pupil of the eye.

Myopic Short-sighted.

Neoplasm

(orbital, intracranial)

An abnormal growth of tissue that can be benign or malignant. Also

called tumour.

Neovascular glaucoma

(NVG)

Classied as a secondary glaucoma. Delayed diagnosis or poor

management can result in complete loss of vision or even the loss of the

globe itself. Patients may present with severe pain. Seek urgent referral to

an ophthalmologist.

No perception of light

(NPL)

A level of vision where, with one eye covered, the patient is unable to

reliably perceive light. Compare light perception.

Non-accidental injury

(NAI)

A non-accidental injury (NAI) is dened as any abuse purposefully inicted

on a person.

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Term Denition

Non-arteritic anterior

ischaemic optic

neuropathy (NAION)

Optic nerve dysfunction secondary to ischaemia with resulting disc

swelling and subsequent pallor. It is not associated with vasculitis such as

giant cell arteritis (GCA). It is associated with cardiovascular risk factors,

especially hypertension.

Occipital lobe lesions The occipital lobes are one of four main lobes of the cerebral cortex.

Lesions in this area can affect visual perception, colour recognition,

reading and reading comprehension, as well as depth and the movement of

objects. If severe, can cause cortical blindness.

Oculocardiac reex A potentially fatal reex that occurs due to stimulation of the trigeminal

nerve. The resultant massive parasympathetic outow mediated by the

vagus nerve can cause bradycardia, hypotension and life-threatening

arrhythmias. Entrapment of extraocular muscles by periorbital fractures

can cause oculocardiac reex.

Open globe injury A full thickness injury to the cornea, sclera or both.

Ophthalmia neonatorum Neonatal conjunctivitis contracted by newborns during delivery through an

infected birth canal.

Ophthalmoplegia Weakness or paralysis of one of the extraocular muscles that control eye

movement and keep the eye in place.

Optic nerve dysfunction Optic nerve function can be tested by combining examination of the

various modalities: visual acuity, pupil function, peripheral elds, colour

vision and colour saturation.

Optic neuritis A demyelinating inammation of the optic nerve.

Orbital cellulitis Inammation of eye tissues behind the orbital septum. It most commonly

refers to an acute spread of infection into the eye socket from either the

adjacent sinuses or through the blood.

Palpebral ssure Space between the upper and lower eyelid edges.

Penetrating eye injury When an object penetrates through the globe with no exit wound.

Periorbital cellulitis Inammation and infection of the eyelid and portions of skin around the

eye, anterior to the orbital septum. Also known as preseptal cellulitis.

Photopsia Perceived ashes of light. Associated with posterior vitreous detachment,

migraine with aura without headache and retinal break or detachment.

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Term Denition

Pingueculum A yellowish patch or bump on the conjunctiva, near the cornea. This is a

fatty degeneration of the conjunctiva overlying the inner or (less

commonly) outer part of the white of the eye. This is a benign condition,

usually requiring no treatment. Articial tears may help to relieve discomfort.

Posterior synechiae Pathological condition: adhesion of the iris to the cornea/lens.

Posterior vitreous

detachment (PVD)

A condition of the eye in which the vitreous membrane separates from the

retina. It refers to the separation of the posterior hyaloid membrane from

the retina anywhere posterior to the vitreous base.

Presbyopia Loss of near vision caused by the loss of elasticity of the lens of the eye,

occurring typically in middle and old age.

Preseptal cellulitis Inammation and infection of the eyelid and portions of skin around the

eye, anterior to the orbital septum. Also known as periorbital cellulitis.

Primary gaze Gaze position determines the effect of extraocular muscle contractions on

the rotation of the eye. Primary gaze is when the eyes look straight ahead.

Prolapse Pathologic condition: slip/falling out of place of a part, e.g. iris may fall

through a wound.

Proptosis Protrusion of the eyeball. Also known as exophthalmos and is usually used

when describing proptosis due to Graves’ disease.

Pterygium A brovascular overgrowth of the conjunctiva onto the cornea.

Ptosis Drooping of the upper eyelid, indicative of third nerve palsy, Horner

syndrome, injury or swelling of the eyelid.

Ptosis measurement Lid crease height, margin reex distance (MRD) and levator function

measurements are needed. Ensure the patient's head in a normal position

with eyebrows relaxed.

Red reex The red reection seen through the pupil from the retina. This is similar to

‘red eye’ in ash photography. The reex is missing if there is an opacity at

the cornea, anterior chamber, lens and vitreous or if the retina is detached.

Reduced vision/

decrease in vision acuity

A decreased capacity of vision that is not corrected by glasses.

Relative afferent pupillary

defect (RAPD)

A pattern of pupil abnormality which is tested by the ‘swinging torch test’.

Also known as Marcus Gunn pupil. Abnormal pupillary response in which

the pupil initially dilates in response to bright light after bright light has

been shone in the contralateral (normal) eye.

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Term Denition

Retinal tear/detachment

(RD)

A disorder of the eye in which the retina peels away from its underlying

layer of support tissue.

Retrobulbar haemorrhage A rare, rapidly progressive, sight-threatening emergency that results in an

accumulation of blood in the retrobulbar space. It can occur due to orbital

trauma, complications of eyelid or orbital surgery or any process that can

affect the blood supply to the eye. Immediate referral to an

ophthalmologist is needed.

Retropulsion A push back of the eye. Used in eye examination to detect the level of

resistance and orbit mobility.

Scleritis Inammation of the sclera.

Scotoma Blind spot in an otherwise normal vision eld.

Seidel test A test used to reveal ocular leaks from the cornea, sclera or conjunctiva

following an injury.

Seventh (7th) cranial

nerve palsy

Can cause paralysis of facial muscles on that side and may result in the

inability to close the eye (lagophthalmos). This leads to exposure of the

corneal surface, which can rapidly cause irreversible corneal damage and

blindness. Seek immediate referral to an ophthalmologist.

Sixth (6th) cranial nerve palsy Causes the inability to abduct the eye. The patient will classically describe

horizontal binocular diplopia that is worse on looking to the affected side,

and either less marked (or resolved) on looking in the opposite direction or

at a near target. Causes that must be excluded include giant cell arteritis

(GCA), compression by a tumour and trauma. Bilateral sixth nerve palsy

can occur if there is elevated intracranial pressure.

Stroke A medical emergency when blood ow to the brain is blocked. Seek

neurological referral.

Stye An infection of an oil gland in the eyelid. Also known as hordeolum.

Subconjunctival haemorrhage Bleeding underneath the conjunctiva.

Subtarsal foreign body Usually in the upper eyelid. Symptoms include a foreign body sensation,

watering and pain.

Supercial punctate

epithelial defect

Damage of the epithelium of the cornea in a pinpoint pattern under a slit

lamp. Symptoms are nonspecic, including red eye, tearing, foreign body

sensation, photophobia and burning. The eye may appear red with a visible

foreign body or linear corneal abrasion.

Eye Emergency Manual December 2023

Agency for Clinical Innovation 145 aci.health.nsw.gov.au

Term Denition

Symblepharon Pathologic condition: adhesion of the eyelid conjunctiva to the conjunctiva

of the globe.

Tarsal conjunctival The part of the conjunctiva that lines the inside surface of the eyelid.

Temporal arteritis See giant cell arteritis (GCA).

Third (3rd) cranial nerve palsy Classically causes upper lid ptosis, anisocoria (pupil larger on affected

side), downwards and lateral deviation of the affected eye and an inability

to adduct or elevate the eye. Lesser degrees of palsy can result in a minor

ptosis or only partial movement decits. Causes that must be excluded are

an aneurysm of the posterior communicating artery compressing the third

cranial nerve, another intracranial mass or pathology in the cavernous

sinus, giant cell arteritis (GCA) and trauma.

Thyroid eye disease

(TED)

An autoimmune disease that causes inammation of the eye muscles and

fatty tissue behind the eyes. This can cause the eyes to be pushed forward

so the eyes ‘bulge’. Associated with Graves' disease.

Transient visual obscuration Temporary or momentary loss of vision in one or both eyes. May be a

symptom of a number of conditions depending on its clinical features.

Trichiasis A condition (such as entropion) resulting in the eyelashes rubbing against

the cornea causing discomfort and the potential for ulceration.

Ulceration Pathologic condition: loss of substance in skin/mucous tissue due to

gradual necrosis of the tissue.

Uvea Term used to describe the ‘middle’ layer of the eye’s internal structure,

between the retina and the sclera. It comprises the choroid, ciliary body

and iris. Visible uveal tissue following trauma indicates that the globe

is ruptured.

Uveal contents The vascular middle layer of the eye constituting the iris, ciliary body and

the choroid.

Uveitis Inammation of the middle layer of tissue of the uvea (eye wall). Symptoms

include eye redness, pain and blurred vision. Can be unilateral or bilateral.

Valsalva retinopathy Valsalva retinopathy is a preretinal haemorrhage caused by a sudden

increase in intrathoracic or intra-abdominal pressure. Seek an urgent

referral to an ophthalmologist.

Vitreous haemorrhage The extravasation or leakage of blood into the areas in and around the

vitreous humour of the eye.