Emergency Cases in Ophthalmology

dr.Muhammad Yusran, SpM, MSc.

Department of Ophthalmology Faculty of Medicine Universitas Lampung/RSAM

Emergency

• A situation that poses an immediate risk to health, life, property, or environtment.

• Required urgent intervention to prevent worsening of the situation

Emergency Cases in Ophthalmology

• Acute Angle Closure Glaucoma• Ocular Trauma• Central Retina Artery Occlusion (CRAO)• Traumatic Optic Neuropathy• Retrobulbar Hemmorage

Glaucoma

• The term glaucoma refers to a group of diseases that have in common a characteristic optic neuropathy with associated visual function loss

• Elevated intraocular pressure (IOP) is one of the primary risk factors.

• Three factors determine the lOP:– The rate of aqueous humor production by the

ciliary body– Resistance to aqueous outflow across the

trabecular meshwork-Schlemm's canal– System the level of episcleral venous pressure

Aqueous Flow

Classification

Acute Angle Closure

Findings during an acute attack of angle-closure glaucoma• Two of the following symptom sets:

– Periorbital or ocular pain– Diminished vision– Specific history of rainbow haloes with blurred vision

• IOP >21 mmHg plus three of the following findings:– Ciliary flush– Corneal edema– Shallow anterior chamber– Anterior chamber cell and flare– Mid-dilated and sluggishly reactive pupil– Closed angle on gonioscopy– Diminished outflow facility– Hyperemic and swollen optic disc– Constricted visual field

Findings suggesting previous episodes of acute angle-closure glaucoma– Peripheral anterior synechiae– Posterior synechiae to lens– Glaukomflecken– Sector or generalized iris atrophy– Optic nerve cupping and/or pallor– Visual field loss– Diminished outflow facility

Signs of postcongestive angle-closure glaucoma

• Folds in Descemet membrane

• Stromal iris atrophy with spiral-like configuration

• Posterior synechiae • Fixed dilated pupil• Fine pigment on iris • Glaukomflecken

Clinical Examination

• Diminished visual acuity.• Perilimbal conjunctival hyperemia (i.e., ‘ciliary flush’).• Corneal edema, at times involving only the epithelium,

but occasionally thickening the stroma and precipitating striae.

• A shallow anterior chamber both centrally and peripherally.

• Minimal-to-moderate anterior chamber reaction caused by increased aqueous humor protein concentration.

• A moderately dilated, vertically oval, sluggish, or nonreactive pupil. The high IOP causes ischemia and paresis of the pupillary sphincter.

• Markedly elevated IOP, usually in the range of 35–75 mmHg.

• Hyperemic, swollen optic disc

Treatment

• Immediate medical therapy is required for lowering the IOP

• Protection of the fellow eye is initiated with medical treatment to reduce the IOP, until the acute attack is resolved and a prophylactic iridotomy can be performed

• Laser iridotomy in both the involved and fellow eyes

• Long-term glaucoma surveillance and IOP management of both eyes

Medical Treatment

Surgical Treatment

Iridotomy by using NdYag Laser

Filtering Surgeries

Trabeculectomy

Trabeculectomy

Trabeculectomy

Chemical Injuries

• This is the insult that requires the most urgent intervention

• Alkali agents cause colliquative necrosis: the destruction of tissue continues as long as the agent is present. The agent can penetrate intraocularly, resulting in severe late complications such as secondary glaucoma.

• Acid agents cause coagulative necrosis: the process slows down and eventually stops tissue destruction beyond the original insult

Etiology

Grading System

Treatment Guidelines

• Step 1: Promote ocular surface epithelial recovery

• Step 2: Apply supportive repair (augment collagen production and/or minimize collagenase activity)

• Step 3: Control inflammation

Specific Treatment

• Elimination of residual alkali or acid from the eye

1. Irrigate copiously– No therapeutic differences have been identified

between normal saline, normal saline with bicarbonate, lactated Ringer’s, balanced salt solution(BSS), and BSS-plus.

– Try to use other neutral fluids.– irrigation for 15 to 30 minutes is recommended.

2. Evert the upper lid and irrigate the fornices. 3. Check the pH a few minutes after irrigation;

continue irrigating until the pH reaches 7.0.4. Remove remnants of the agent (e.g., plaster)

from the fornices mechanically with a moistened cotton tipped applicator or a jeweler’s forceps. Double eversion provides the best access to the upper fornix.

• Débridement– Necrotic corneal epithelium should be débrided to

allow proper migration of adjacent, viable epithelium.

– Devitalized conjunctival epithelium should also be débrided to remove a nidus of persistent inflammation, which can also retard corneal reepithelialization

• Medical treatment