Eye Emergencies

Universal eye workup
  • Visual acuity (each eye, with correction) — the "vital sign" of the eye
  • Pupils — size, reactivity, (swinging flashlight)
  • + confrontation visual fields
  • () — defer if open globe suspected
  • Slit lamp + fluorescein — Seidel test to r/o perforation
  • Fundoscopy ± dilation; ocular (no pressure if globe rupture)
Vision-threatening — STAT ophthalmology
Central Retinal Artery Occlusion (CRAO)
ADMIT

Sudden painless monocular vision loss; pale retina with cherry-red fovea, +.

Workup / diagnostics
  • Visual acuity, , slit lamp, dilated fundus exam
  • : hyperechoic 'retrobulbar spot sign' in optic nerve
  • Stroke workup — CTA head/neck, ECG, troponin, lipids, A1c
  • ESR/CRP + temporal artery exam if age >50 (rule out )
Management
  • Ocular massage (digital, 10–15s on/off)
  • Lower : timolol 0.5% 1 gtt, acetazolamide 500 mg IV/PO
  • Lie supine; consider paper-bag rebreathing (↑CO₂ → vasodilate)
  • If suspected: 1 g IV + biopsy
  • Stroke pathway — NOT routinely indicated; admit to stroke service
Disposition

ADMIT — stroke equivalent; neuro/stroke + ophtho consult

Central Retinal Vein Occlusion (CRVO)
URGENT OPHTHO

Painless monocular vision loss; diffuse retinal hemorrhages, dilated tortuous veins.

Workup / diagnostics
  • VA, , slit lamp, dilated fundus
  • BP, glucose, lipids, CBC, coags (hypercoag if <50)
  • Workup for HTN, DM, glaucoma
Management
  • No emergent ED therapy — anti-VEGF / laser by ophtho
  • Manage if elevated
Disposition

Outpt ophtho within 24 h; admit only if neovascular glaucoma or systemic illness

Acute Angle-Closure Glaucoma
ADMIT

Acute unilateral eye pain + halos + N/V; mid-dilated nonreactive pupil, hazy cornea, rock-hard globe, >30.

Workup / diagnostics
  • (tonometry) — usually 40–80 mmHg
  • Slit lamp: shallow anterior chamber, corneal edema
  • VA, pupil exam
Management
  • Timolol 0.5% 1 gtt + apraclonidine 1% 1 gtt + 1–2% 1 gtt q15 min
  • Acetazolamide 500 mg IV (or PO) ± mannitol 1–2 g/kg IV if refractory
  • + analgesia; keep supine, avoid dark rooms
  • Definitive: laser peripheral iridotomy by ophtho
Disposition

ADMIT or hold for STAT ophtho — needs iridotomy; outpt only if normalized and ophtho seen

Retinal Detachment
URGENT OPHTHO

Painless flashes and floaters, then a progressive 'curtain' across the visual field.

Workup / diagnostics
  • VA, confrontation fields, dilated fundus exam
  • : hyperechoic membrane tethered at optic nerve (mac-off vs mac-on)
Management
  • Keep NPO, head positioning per ophtho
  • No ED-specific therapy
Disposition

STAT ophtho — same-day repair if macula-on; admit/transfer if no ophtho available

Globe Rupture / Open Globe
ADMIT

Trauma + teardrop/peaked pupil, 360° subconj hemorrhage, +Seidel, or extruded uveal tissue.

Workup / diagnostics
  • DO NOT check , no eye drops, no pressure
  • CT orbit thin-cuts (NO MRI if metallic FB suspected)
  • Visual acuity (gentle), pupil exam
Management
  • Rigid eye shield (no patch)
  • , analgesia, sedation as needed (avoid Valsalva)
  • IV antibiotics: + ceftazidime (or )
  • Tetanus update
  • NPO for OR
Disposition

ADMIT — emergent OR with ophtho

Retrobulbar Hematoma / Orbital Compartment Syndrome
ADMIT

Periocular trauma + tense proptosis, ↓vision, +, >40 — cut now, don't wait for CT.

Workup / diagnostics
  • (>40 + vision loss = act now)
  • CT orbit — confirms hematoma
  • VA, pupil
Management
  • LATERAL CANTHOTOMY + CANTHOLYSIS at bedside if vision-threatening — do not wait for CT
  • Elevate HOB, mannitol/acetazolamide as adjunct
Disposition

ADMIT — ophtho/OMFS; sight-saving procedure is ED-performed

Chemical Burn (Alkali > Acid)
URGENT OPHTHO

Chemical splash + pain and blurred vision; perilimbal blanching = worst prognosis.

Workup / diagnostics
  • Check pH BEFORE other exam (normal 7.0–7.4)
  • VA, slit lamp + fluorescein after irrigation
Management
  • IRRIGATE IMMEDIATELY — LR or NS via Morgan lens, 1–2 L per eye until pH 7.0–7.4, recheck q30 min
  • Topical anesthetic (proparacaine) before irrigation
  • Cycloplegic (cyclopentolate 1%), topical abx (erythromycin/), oral analgesia
  • Severe (alkali, limbal ischemia) → topical steroid + ascorbate per ophtho
Disposition

Mild: outpt ophtho 24 h. Moderate–severe / alkali / limbal ischemia: ADMIT

Endophthalmitis
ADMIT

Pain + ↓vision days after intraocular surgery or injection; hypopyon, severe inflammation.

Workup / diagnostics
  • VA, slit lamp (hypopyon),
  • Vitreous tap + intravitreal abx by ophtho
Management
  • Intravitreal + ceftazidime (ophtho)
  • Systemic abx if endogenous source
Disposition

ADMIT — emergent ophtho

Giant Cell Arteritis (GCA) / Arteritic AION
ADMIT

Age >50 + new headache, jaw claudication, scalp tenderness; transient or sudden vision loss.

Workup / diagnostics
  • ESR (>50), CRP, platelets
  • VA, , fundus: pallid disc edema
  • Temporal artery biopsy (within 1–2 wk)
Management
  • 1 g IV daily x 3 days, then 1 mg/kg PO
  • 81 mg
Disposition

ADMIT for IV steroids; do NOT wait for biopsy to start treatment

Urgent — same-day to 24-h ophtho
Corneal Ulcer / Bacterial Keratitis
URGENT OPHTHO

Contact lens wearer with pain and photophobia; focal white corneal infiltrate on slit lamp.

Workup / diagnostics
  • Slit lamp + fluorescein (infiltrate + epithelial defect)
  • Cultures by ophtho if large/central
Management
  • Topical or ofloxacin q1h around the clock
  • Add fortified + tobramycin if central/large per ophtho
  • Cycloplegic for comfort; NO patch, NO steroids without ophtho
  • Discontinue contacts
Disposition

Ophtho within 24 h; admit if central, >2 mm, or hypopyon

Herpes Simplex Keratitis
URGENT OPHTHO

Unilateral pain, photophobia, ↓corneal sensation; branching dendritic ulcer on fluorescein.

Workup / diagnostics
  • Slit lamp + fluorescein — dendrites with terminal bulbs
  • Check corneal sensation (decreased)
Management
  • Trifluridine 1% 1 gtt 9x/day OR ganciclovir gel 5x/day
  • PO acyclovir 400 mg 5x/day as alternative
  • NO topical steroids in ED
Disposition

Outpt ophtho 1–3 days

Herpes Zoster Ophthalmicus
URGENT OPHTHO

V1 dermatomal vesicles; Hutchinson sign (nasal tip lesion) predicts globe involvement.

Workup / diagnostics
  • Slit lamp + fluorescein (pseudodendrites)
  • Check
Management
  • Valacyclovir 1 g PO TID x 7 days (start within 72 h)
  • Erythromycin ointment to lid lesions
  • Pain control
Disposition

Outpt ophtho 24 h if eye involved; admit if immunocompromised or severe

Iritis / Anterior Uveitis
URGENT OPHTHO

Deep ache, photophobia, consensual photophobia, perilimbal (ciliary) flush; cell + flare.

Workup / diagnostics
  • Slit lamp: cell and flare in anterior chamber
  • Check
  • If recurrent: HLA-B27, RPR, ANA, CXR, etc.
Management
  • Cycloplegic (cyclopentolate 1% TID or homatropine 5%)
  • Topical prednisolone 1% q1–6h per ophtho
Disposition

Outpt ophtho 24–48 h

Orbital Cellulitis
ADMIT

Fever + proptosis, painful/limited , ↓vision; preseptal lacks these globe signs.

Workup / diagnostics
  • CT orbit with contrast
  • CBC, blood cultures
  • VA, pupil, ,
Management
  • IV + (or )
  • Add if intracranial extension
  • ENT/ophtho consult; surgical drainage if abscess
Disposition

ADMIT for IV abx; preseptal in well-appearing adult may go outpt PO abx + 24 h follow-up

Hyphema
URGENT OPHTHO

Layered blood in the anterior chamber after blunt ocular trauma; grade by % AC fill.

Workup / diagnostics
  • VA, , slit lamp (grade by % AC)
  • Sickle cell screen if at risk (↑ rebleed/ risk)
  • CT orbit if mechanism severe
Management
  • Eye shield, HOB up 30°, limit activity
  • Topical cycloplegic + topical steroid per ophtho
  • Manage (avoid CAIs in sickle cell)
  • (avoid Valsalva)
Disposition

Admit if >50% AC, ↑, sickle cell, kids, or non-compliant; otherwise daily ophtho

Often outpatient — ophtho follow-up
Corneal Abrasion
OUTPT FOLLOW-UP

Acute FB sensation, tearing, photophobia; discrete fluorescein uptake, no infiltrate.

Workup / diagnostics
  • Slit lamp + fluorescein — evert lids to r/o FB
  • Seidel test to r/o perforation
Management
  • Erythromycin ointment QID or polymyxin/trimethoprim drops
  • If contact lens wearer: or ofloxacin (pseudomonas coverage); NO patch
  • Topical NSAID (ketorolac) or PO analgesia; NO topical anesthetics for home use
  • Tetanus if dirty
Disposition

Outpt ophtho 24–48 h if large, central, or contact-related; otherwise PCP

Corneal Foreign Body
OUTPT FOLLOW-UP

Embedded corneal FB after grinding or hammering; metallic FBs leave a rust ring.

Workup / diagnostics
  • Slit lamp + fluorescein, Seidel, evert lids
  • CT orbit if intraocular FB suspected
Management
  • Topical anesthetic, remove with 25–27 g needle or burr under slit lamp
  • Antibiotic ointment, cycloplegic for comfort
Disposition

Outpt ophtho 24 h for rust ring removal

Subconjunctival Hemorrhage
OUTPT FOLLOW-UP

Painless flat sheet of blood under the conjunctiva; vision, pupil, and normal.

Workup / diagnostics
  • VA, slit lamp (confirm flat, no globe injury)
  • If trauma + 360° → r/o globe rupture
  • Check BP, consider coags if recurrent
Management
  • Reassurance — resolves in 1–2 wk
  • Artificial tears prn
Disposition

PCP follow-up; no ophtho needed unless

Conjunctivitis (Bacterial / Viral / Allergic)
OUTPT FOLLOW-UP

Bilateral red eye with discharge; vision, pupil, and cornea exam are normal.

Workup / diagnostics
  • VA, slit lamp + fluorescein (r/o keratitis)
  • Consider gonococcal/chlamydial if hyperpurulent or neonate
Management
  • Bacterial: erythromycin ointment or trimethoprim/polymyxin
  • Gonococcal: 1 g IM + saline irrigation — ADMIT/urgent ophtho
  • Viral: supportive, cool compresses, contact precautions
  • Allergic: olopatadine, oral antihistamine
Disposition

PCP; ophtho only if vision change, severe, or contact lens wearer

Stye (Hordeolum) / Chalazion
OUTPT FOLLOW-UP

Focal lid nodule — tender at the lash line (stye) or painless mid-tarsal (chalazion).

Workup / diagnostics
  • Clinical; slit lamp to r/o preseptal cellulitis
Management
  • Warm compresses QID, lid hygiene
  • Topical erythromycin if drainage
  • Refer for I&D if persistent
Disposition

PCP/ophtho non-urgent

UV Keratitis (Welder's / Snow Blindness)
OUTPT FOLLOW-UP

Bilateral severe pain 6–12 h after welding/snow/tanning; diffuse punctate fluorescein uptake.

Workup / diagnostics
  • Slit lamp + fluorescein
Management
  • Cycloplegic (cyclopentolate), erythromycin ointment, PO analgesia
  • Resolves in 24–48 h
Disposition

PCP/ophtho 24–48 h

Posterior Vitreous Detachment
URGENT OPHTHO

Acute floaters and flashes with intact vision and no curtain or field cut.

Workup / diagnostics
  • VA, dilated fundus exam (r/o tear/detachment)
  • if available
Management
  • No ED therapy
Disposition

Ophtho within 24–72 h to r/o retinal tear

Pearls
  • NEVER prescribe topical anesthetics for home use — causes corneal melt
  • NEVER patch a contact lens wearer's abrasion (pseudomonas risk)
  • NEVER give topical steroids without ophtho input (HSV, fungal worsening)
  • Painless monocular vision loss = CRAO, CRVO, retinal detachment, vitreous hemorrhage, ION until proven otherwise
  • Trauma + ↓vision + proptosis + ↑IOP = lateral canthotomy NOW