Ophthalmologic Emergencies & Acute Visual Loss

Resuscitation Quick Ribbon (First 2 Minutes)

Chemical Eye Burn:IRRIGATE FIRST (Morgan lens, 2–4L saline) until pH = 7.0–7.4 | Check pH 5 min post-irrigation

Acute Angle-Closure Glaucoma:Timolol 0.5% + Apraclonidine 1% + Pilocarpine 2% + IV Acetazolamide 500 mg (IOP goal < 20 mmHg)

Open Globe / Ruptured Globe:Rigid Fox eye shield | NO drops, NO tonometry | IV Vancomycin + Ceftazidime | Emergent OR repair

CRAO ('Eye Stroke'):Sudden painless vision loss + cherry-red spot | Digital ocular massage | Emergent stroke protocol

Contact Lens Abrasion:Cover Pseudomonas (Ciprofloxacin / Ofloxacin 0.3% drops) | NEVER patch a contact lens wearer

Bottom-Line Clinical Pearl

Immediate visual acuity is the vital sign of the eye; however, in chemical ocular burns, instant copious irrigation with normal saline takes priority before any exam until pH reaches 7.0–7.4. Acute angle-closure glaucoma (IOP > 40 mmHg) requires immediate multi-agent medical decompression (timolol, apraclonidine, pilocarpine, and IV acetazolamide). In suspected open globe, place a rigid Fox eye shield, avoid all eye drops or tonometry, and consult ophthalmology emergently.

1. Immediate Triage & Visual Acuity

Visual acuity is the definitive functional 'vital sign' of the eye and must be checked in every eye complaint before medical examination, using a Snellen chart at 20 feet (or near-card at 14 inches) with the patient's corrective lenses. If unable to read letters, document: Counting Fingers (CF), Hand Motion (HM), Light Perception (LP), or No Light Perception (NLP).

The Sole Exception: In chemical ocular burns (acids or alkalis), INSTANT COPIOUS IRRIGATION precedes visual acuity, history, or slit lamp examination. Every second of delay in an alkali burn leads to deeper liquefactive necrosis of corneal stroma and stem cells.

2. Acute Angle-Closure Glaucoma (AACG)

Occurs when the peripheral iris covers the trabecular meshwork, completely obstructing aqueous humor drainage from the anterior chamber. Intraocular pressure (IOP) spikes rapidly from normal (10–21 mmHg) to > 40–70 mmHg, causing ischemic optic neuropathy and permanent blindness if untreated within hours.

Presentation & Physical Signs	Diagnostic Triad	Emergency Pharmacotherapy
Severe unilateral eye pain, headache, nausea, vomiting, rainbow halos around lights	1. Rock-hard globe to gentle palpation 2. Fixed mid-dilated pupil (~4–6 mm) 3. Hazy 'steamy' cornea with ciliary flush	Topical Timolol 0.5% (Beta-blocker) 1 drop Topical Apraclonidine 1% (Alpha-2 agonist) 1 drop Topical Pilocarpine 2% (Miotic) 1 drop (after IOP < 40) IV Acetazolamide 500 mg IV Mannitol 1–2 g/kg over 45 min if refractory

Definitive Treatment: Medical therapy temporizes intraocular pressure. The definitive cure is Laser Peripheral Iridotomy (LPI) performed by an ophthalmologist on BOTH the affected and contralateral eye (which is anatomically predisposed).

3. Sudden Painless Vision Loss: CRAO vs. CRVO vs. Retinal Detachment

Acute painless monocular visual loss is an ischemic or structural emergency requiring rapid fundoscopic and bedside POCUS assessment.

Condition	Etiology & Mechanism	Fundoscopic & POCUS Findings	Emergency Management
Central Retinal Artery Occlusion (CRAO)	Thromboembolism from carotid artery or cardiac source; vasospasm; giant cell arteritis	Pale milky retina with CHERRY-RED SPOT at macula; boxcar segmentation of blood columns; Afferent Pupillary Defect (Marcus Gunn)	Emergency Code Stroke activation (intra-arterial tPA considered < 4.5 hr); digital ocular massage; topical timolol + acetazolamide; check ESR/CRP for giant cell arteritis (high-dose IV steroids)
Central Retinal Vein Occlusion (CRVO)	Thrombosis of central retinal vein linked to HTN, diabetes, glaucoma, hypercoagulability	'Blood and Thunder' fundus: widespread retinal hemorrhages, cotton-wool spots, tortuous engorged veins	Ophthalmology consult; anti-VEGF therapy; control hypertension and intraocular pressure
Retinal Detachment	Rhegmatogenous tear allowing vitreous fluid into subretinal space	Visual 'curtain falling'; photopsia (flashes) and floaters. POCUS: undulating hyperechoic membrane floating in posterior chamber, tethered to optic disc	Strict bed rest; urgent ophthalmology repair (pneumatic retinopexy, scleral buckle, or vitrectomy) within 24–48h if macula is 'on'

4. Open Globe / Ruptured Globe

Full-thickness laceration of the cornea or sclera from blunt or penetrating trauma. High risk of endophthalmitis and permanent vision loss.

Clinical Findings	Diagnostic Testing	Critical 'Do Nots' in Open Globe
Teardrop pupil (points toward laceration) Flattened anterior chamber Extruded uveal tissue (brown pigment) 360-degree 'bullous' subconjunctival hemorrhage	Positive Seidel Test: Concentrated fluorescein dye is diluted by streaming aqueous humor (appears as green waterfall under cobalt blue light). Non-contrast CT orbits (1 mm thin cuts) for intraocular foreign body	1. DO NOT measure intraocular pressure (tonometry) 2. DO NOT apply eye patches (compresses globe) 3. DO NOT instill eye drops (toxic to intraocular structures) 4. DO NOT remove impaled foreign objects

Open Globe Protocol: Place a rigid Fox metal eye shield resting on the bony margins of the brow and cheek (never touching the globe). Elevate head of bed 30–45 deg. Administer IV Ondansetron (prevent vomiting and Valsalva). Update tetanus. Give broad-spectrum IV antibiotics: Vancomycin 15–20 mg/kg IV + Ceftazidime 2g IV. NPO for emergent operative repair.

5. Chemical Ocular Burns

Alkalis (ammonia, lye, drain cleaner, cement) cause liquefactive necrosis and penetrate deep into ocular structures. Acids (battery acid) cause coagulative necrosis with a protective eschar but can still cause severe corneal melt.

Instill topical anesthetic (Proparacaine 0.5% or Tetracaine 0.5%).
Insert Morgan Lens and connect to 1–2 liters of Normal Saline or Ringer's Lactate; begin wide-open continuous irrigation.
Sweep the upper and lower fornices with a moistened cotton swab to remove retained particulate matter (especially with cement or lime).
Stop irrigation after 1–2L; wait 5 minutes, and check conjunctival fornix pH using litmus paper or urine dipstick.
Continue irrigation until pH reaches neutral (7.0–7.4). Goal is 7.0–7.4 confirmed 30 minutes after cessation of irrigation.

6. Corneal Abrasion, Ulcer & Orbital Infections

Pathology	Slit Lamp & Fluorescein Signs	Management & Antibiotic Selection
Corneal Abrasion (Non-contact lens)	Superficial epithelial defect glowing bright green under cobalt blue light	Erythromycin ophthalmic ointment QID or Polymyxin B/Trimethoprim drops. Heals in 24–48 hours.
Corneal Abrasion (Contact Lens Wearer)	Epithelial defect in patient wearing soft contacts	Must cover Pseudomonas aeruginosa: Ciprofloxacin 0.3% or Ofloxacin 0.3% drops QID. NEVER patch the eye (creates dark warm incubator for Pseudomonas corneal melt). Discard contacts and case.
Bacterial Keratitis / Corneal Ulcer	White corneal infiltrate / 'round white spot' visible to naked eye; hypopyon (pus in anterior chamber)	Ophthalmologic emergency! Intense fluoroquinolone drops (Ofloxacin q1h around the clock) + emergent ophtho consult for corneal scrapings. Risk of corneal perforation.
Herpes Simplex Keratitis (HSV)	Branching dendritic ulcer with terminal end-bulbs	Topical Trifluridine 1% drops or oral Acyclovir / Valacyclovir. CONTRAINDICATION: NEVER prescribe topical corticosteroids (leads to geographic ulcers and corneal melting).
Orbital vs. Preseptal Cellulitis	Orbital: Proptosis, ophthalmoplegia (pain with eye movement), decreased vision. Preseptal: Eyelid erythema only, normal vision, painless eye movement	Orbital: Emergency CT orbits/sinuses with contrast; IV Vancomycin + Ceftriaxone; ENT/Ophtho consult for surgical drainage. Preseptal: Outpatient Augmentin if mild.