Chapter 149. Ocular Emergencies

Preseptal and Postseptal Cellulitis

Preseptal cellulitis is an infection of the periorbital tissues, whereas postseptal cellulitis involves the orbit. These disease entities occur mostly in patients < 10 years of age. They may present nearly identically with typical symptoms of erythema, warmth, tenderness to palpation. In preseptal cellulitis, the visual acuity and pupillary responses are normal, and there is the complete absence of any pain with extraocular movements, proptosis, and diplopia. If any of these characteristics are present, or if there is concern about postseptal involvement, then a CT scan (or MRI) of the orbit (axial and coronal views, with and without contrast) should be obtained to rule out orbital involvement. Preseptal cellulitis in nontoxic patients may be treated as an outpatient with amoxicillin/clavulanic acid (20 milligrams/kilogram PO divided every 12 hours; 500 milligrams PO tid in adults) with 24 hours follow-up with an ophthalmologist. In preseptal cellulitis in children <5 years or adults with significant comorbidities or in cases of postseptal cellulitis, an emergent ophthalmology consultation for admission should be obtained. Empiric intravenous therapy should begin with cefuroxime (50 milligrams/kilogram IV every 8 hours) or ceftriaxone (50 milligrams/kilogram every 12 hours), or ampicillin-sulbactam (50 milligrams/ kilogram IV every 6 hours), with IV vancomycin added if MRSA is suspected.

Stye (External Hordeolum) and Chalazion

A stye or external hordeolum, is an acute infection of an oil gland at the lash line that appears as a pustule at the lid margin. A chalazion is an acute or chronic noninfectious inflammation of the eyelid secondary to meibomian gland blockage in the tarsal plate. When it is acute, a chalazion may be painful, but is usually painless when chronic. A stye or acute chalazion is treated with warm, wet compresses 4 times daily and with erythromycin 0.5% ophthalmic ointment twice daily for 7 to 10 days. Persistent or recurrent lesions should be referred to an ophthalmologist for further evaluation and treatment.

Bacterial Conjunctivitis

Bacterial conjunctivitis presents as eyelash matting, mild to moderate mucopurulent discharge, and conjunctival inflammation. Fluorescein staining of the cornea should be performed in patients with suspected conjunctivitis to avoid missing abrasions, ulcers, and dendritic lesions. Topical antibiotics (Table 149-1) are appropriate. In children, Haemophilus influenza and Moraxella catarrhalis are considerations; therefore, if erythromycin ointment is ineffective, a change in antibiotics should be initiated. Contact lens wearers should receive topical antibiotic coverage for Pseudomonas, such ciprofloxacin or tobramycin. The lens should be discarded and not replaced until the infection has completely resolved. In patients younger than 2 months, sulfacetamide 10% solution 1 drop every 2 to 3 hours for 5 to 7 days may be used. Gentamicin has fallen out of favor due to the high incidence of ocular irritation.

A severe purulent discharge with a hyperacute onset (within 12 to 24 hours) should prompt an emergent ophthalmology consultation for an aggressive workup for possible gonococcal conjunctivitis. Neisseria gonorrhea infections may be confirmed by Gram stain (gram-negative intracellular diplococci). Emergency department (ED) care for N gonorrhea infections include culture, antibiotics (ceftriaxone 1 gram IM) and saline solution irrigation to remove the discharge; for corneal involvement, use ceftriaxone 1 gram IV q12h, tobramycin 1 drop q1h, and doxycycline 100 milligrams PO bid (for possible chlamydial coinfection), and saline solution irrigation 4 times daily.

If bacterial conjunctivitis is present in a neonate, STDs are of primary concern. These are sight-threatening conditions which can be difficult to diagnose, and an emergent ophthalmology consult in the ED is warranted. If gonorrhea is suspected, an inpatient workup for disseminated disease is indicated. If chlamydia, then associated pneumonia must be ruled out prior to discharge. Herpes is also of concern. (See Herpes Simplex below).

Viral conjunctivitis presents as watery discharge, chemosis, and conjunctival inflammation. It is often associated with viral respiratory symptoms and occasionally preauricular lymphadenopathy. Fluorescein staining should be done as in bacterial conjunctivitis, specifically in this case to rule out dendritic lesions. Treatment consists of cool compresses 4 times daily, naphazoline/pheniramine 0.025%/0.3% 1 drop 3 times daily, as needed, for conjunctival congestion or itching, artificial tears 5 or 6 times a day, and ophthalmology follow-up in 7 to 14 days. If a clear distinction between viral and bacterial etiologies cannot be made, consideration should be made to add topical antibiotics (Table 149-1) until reexamination by an ophthalmologist; however, routine use of antibiotics is discouraged. All cases of viral conjunctivitis are extremely contagious, and appropriate transmission precautions must be taken.

Allergic Conjunctivitis

Allergic conjunctivitis presents as pruritus, watery discharge, and chemosis with a history of allergies. There should be no lesions with fluorescein staining and preauricular nodes should be absent. Conjunctival papillae are seen on slit lamp examination. Treatment consists of elimination of the inciting agent, cool compresses 4 times daily, artificial tears 5 or 6 times daily, and naphazoline/pheniramine 0.025%/0.3% 1 drop 4 times daily. Severe cases may require a mild topical steroid such as fluorometholone 0.1% 1 drop 4 times daily for 7 to 14 weeks, but should be only administered in consultation with an ophthalmologist.

Herpes Simplex Virus

Herpes simplex virus (HSV) infection may involve the eyelids, conjunctiva, or cornea. The hallmark dendrite of herpes keratitis appears as a linear branching, epithelial defect with terminal bulbs that stain brightly with fluorescein dye during slit lamp examination. It is essential that HSV infection not be confused with conjunctivitis; hence, the necessity of a slit lamp fluorescein examination in these patients. If the outbreak involves only the eyelids, acyclovir 800 milligrams PO 5 times daily for 7 to 10 days should be prescribed. If the conjunctiva is involved, trifluorothymidine 1% drops or vidarabine 3% ointment 5 times daily should be prescribed. In addition, erythromycin ophthalmic 0.5% ointment twice daily and warm soaks 3 times daily to skin lesions can help prevent secondary bacterial infections. If corneal involvement is present, then the trifluorothymidine 1% drops 9 times daily or vidarabine 3% ointment 5 times daily is used. If an anterior-chamber reaction is present, a cycloplegic agent such as scopolamine 0.25% 1 drop 3 times daily can be used. Acyclovir 800 milligrams PO 5 times daily or famciclovir 500 milligrams 3 times daily for 7 to 10 days may be considered if compliance with topic medications is questionable. Topical steroids are to be strictly avoided. All treatment should be performed in consultation with an ophthalmologist, and follow-up within 1 to 2 days should be scheduled.

When conjunctivitis is present in the neonate, herpes also should be suspected, even in the absence of maternal infection. As with other causes of neonatal conjunctivitis, an emergent ophthalmology consult in the ED is warranted. If herpes is diagnosed or strongly suspected, IV acyclovir (20 milligrams/kilogram IV every 8 hours), trifluorothymidine 1% drops 9 times daily or vidarabine 3% ointment 5 times daily, and a workup for sepsis is indicated.

Herpes Zoster Ophthalmicus

Shingles in a trigeminal distribution with ocular involvement is termed herpes zoster ophthalmicus (HZO). The presence or eventual development of HZO should be suspected in any patient whose shingles involve the tip of the nose (Hutchinson sign). Photophobia and pain secondary to iritis are often present. Slit lamp examination may show a “pseudodendrite,” a poorly staining mucus plaque without epithelial erosion. Acyclovir 800 milligrams PO 5 times a day, famciclovir 500 milligrams 3 times daily, or valacyclovir 1000 milligrams 3 times daily for 7 to 10 days should be prescribed if the skin lesions are younger than 7 days. In addition, erythromycin 2% ointment and warm compresses should be applied to skin lesions. Ocular involvement requires erythromycin 0.5% ophthalmic ointment to the eye twice daily. For comfort, oral opioid analgesia, cycloplegic agents (cyclopentolate 1% 1 drop 3 times daily), and cool compresses are helpful. If iritis is present, prednisolone acetate 1% 1 drop every 1 to 6 hours is effective. However, because topical steroid use in patients with herpes simplex keratoconjunctivitis may be catastrophic, it is imperative that there be no corneal lesions present on slit lamp examination before topical steroids are used. In severe cases, admission and acyclovir IV may be required. For this reason, all cases of suspected HZO require an ophthalmology consultation. All patients younger than 40 years with HZO should undergo an outpatient medical evaluation for a possible immunocompromised state.

Corneal Ulcer

A corneal ulcer is a serious infection of the corneal stroma caused by bacteria including Pseudomonas aeruginosa, viruses including Herpes simplex and Varicella zoster, and fungi. Immunocompromised patients are at risk for fungal or viral etiologies. It is commonly associated with trauma, especially in patients who use extended-wear contact lenses and those who wear lenses while sleeping. Ulcers cause pain, redness, tearing, and photophobia. Slit lamp examination shows a staining corneal defect with a surrounding white hazy infiltrate, and associated iritis and sometimes a hypopyon. Topical ofloxacin 0.3% or ciprofloxacin 0.3% ophthalmic solution should be administered, 1 drop in the affected eye each hour. Antifungal or antiviral antibiotics may be given to immunocompromised patients in consultation with an ophthalmologist. Topical cycloplegics, such as cyclopentolate 1% 1 drop 3 times daily, aid in pain relief. Eye patching is strictly contraindicated because of the risk of worsening a potential Pseudomonas infection. It would be ideal for the patient to be seen by an ophthalmologist in the ED in order to culture the ulcer prior to starting antibiotics. However, if this is not possible, they should see the patient within 12 to 24 hours.

Iritis

Iritis is inflammation of the anterior uveal tract (iris and ciliary body) that has many causes (Table 149-2). It presents with red eye, photophobia, and decreased vision. A hallmark physical examination sign is consensual pain (pain in the affected eye when light is shined in the nonaffected eye). Slit lamp examination reveals WBCs in the anterior chamber, usually with associated flare, and a hypopyon can eventually occur. Fluorescein exam should be done because possibly etiologies may be detected (corneal abrasion, ulcer, or dendrite). Once iritis is diagnosed, an appropriate ED workup for a systemic etiology should be undertaken. Treatment is directed toward the underlying cause, if found, and symptomatic treatment with homatropine or tropicamide (Table 149-1) is helpful. Ophthalmology consultation is appropriate with follow-up in 24 to 48 hours. Steroid drops can be of value, but should only be given if directed by the ophthalmologist.

Endophthalmitis

Endophthalmitis is an infection involving the deep structures of the globe. Patients present with pain and visual loss. It is often seen as a complication of globe violation either from trauma or ocular surgery. Hematologic spread is possible. Pathogens include Staphylococcus, Streptococcus, Haemophilus and Bacillus. Emergency ophthalmology consultation and admission are warranted. Treatment includes intraocular and systemic antibiotics. Initial empiric treatment is vancomycin 1 milligram in 0.1 mL normal saline (N/S) and ceftazidime 2.25 milligrams in 0.1 mL N/S intravitreally (note not IV). Systemic antibiotics are added if bacteremia is suspected. Considerations include clindamycin 600 to 900 milligrams IV q8h, ceftazidime 2 grams IV q8h, and amikacin 7.5 milligrams/kilogram IV once, then 6 milligrams/kilogram q12h. Steroids intravitreally or orally may be used by the ophthalmologist.

Subconjunctival Hemorrhage

This injury is a disruption of conjunctival blood vessels, typically secondary to trauma, sneezing or the Valsalva maneuver. It requires no treatment and usually resolves within 2 weeks. Its primary clinical importance rests in the fact that it can be a sign of significant eye injury when due to trauma, and recurrent episodes should prompt an evaluation for a coagulopathy.

Corneal Abrasion and Ultraviolet (UV) Keratitis

Traumatic abrasions may cause superficial or deep epithelial defects resulting in tearing, photophobia, blepharospasm, and pain. Administration of a topical anesthetic often will facilitate the examination. Proparacaine 0.5% is preferred over tetracaine because it causes less pain upon administration and provides comparable anesthesia. A corneal abrasion will glow green during a fluorescein stain examination when using the cobalt blue light on the slit lamp. A careful search for an ocular foreign body (including upper lid eversion) must be done in the presence of an abrasion, especially when they are multiple and linear. Once the diagnosis of a simple abrasion is made, opioid analgesia should be considered for severe pain. In addition, a cycloplegic (eg, cyclopentolate 1% 1 drop 3 times a day) is traditionally recommended for pain relief, although solid evidence of efficacy is lacking. Simple abrasions are treated with topical antibiotics (Table 149-1). Most patients are treated with erythromycin ointment; however, abrasions associated with contact lens wear should be treated with ciprofloxacin, ofloxacin, or tobramycin. Tetanus status should be updated. Patching corneal abrasions traditionally has been recommended; however, excellent patient comfort can be achieved without it. More importantly, patching does not hasten the healing of abrasions and can greatly harm the patient if the lesions prone to infection (eg, contact lens abrasions or corneal ulcers) are patched. Prescribing topical anesthetics is absolutely contraindicated because repeated use may cause catastrophic corneal damage. All abrasions should be reexamined in 24 hours by an ophthalmologist.

Exposure to UV light from welding (“arc welder's keratitis”), tanning beds, or prolonged sun exposure (especially during eclipses) can cause a diffuse burn to the cornea which appears as diffuse punctate corneal abrasions with edema. Severe pain and photophobia develop 6 to 12 hours after exposure. Treatment is similar to corneal abrasions, but more aggressive pain control is sometimes necessary.

Corneal Foreign Bodies

Superficial foreign bodies of the cornea are removed under slit lamp microscopy with a 25-guage needle, an eye spud, or an ophthalmic burr. Topical anesthesia (eg, proparacaine 0.5%) is used (also instilled in the unaffected eye to depress reflex blinking). For obvious reasons, this procedure should be attempted only in a sober, cooperative patient. Any corneal foreign body deep within the corneal stroma or in the central visual axis should be removed by an ophthalmologist. Metallic foreign bodies often leave an epithelial “rust ring” that may be removed immediately with an eye burr; however, it is often easier to remove in 24 to 48 hours. A corneal abrasion will result from foreign body removal and is treated in the standard manner (cycloplegics, antibiotics). All patients should be referred to an ophthalmologist within 24 hours.

Lid Lacerations

Many small superficial lacerations to the eye lids can be repaired by emergency physicians (see also Chapter 11), however, eyelid lacerations that involve the lid margin, those within 6 to 8 mm of the medial canthus or involving the lacrimal duct or sac, those involving the inner surface of the lid, wounds associated with ptosis, and those involving the tarsal plate or levator palpebrae muscle need repair by an ophthalmologist or plastic surgeon. Lid margin lacerations > 1 mm require closure under magnification by an ophthalmologist, whereas those <1 mm can heal spontaneously. For medial lid lacerations, injury to the lacrimal canaliculi and puncta must be excluded. Fluorescein instilled into the tear layer that appears in an adjacent laceration confirms the injury. Upper lid lacerations that involve the levator mechanism and all through-and-through lid lacerations must be repaired in the operating room. If an ophthalmologist is not immediately available to evaluate a high-risk lid laceration, it is not unreasonable to prescribe cephalexin 500 milligrams PO 4 times daily, erythromycin 2% ointment 4 times daily, and gentle cold compresses with referral for ophthalmic evaluation within 24 hours, as long as any sight-threatening lesions have been excluded.

Blunt Eye Trauma

An eye speculum (or 2 bent paper clips) are useful in visualization of the bluntly injured eye, but care should be taken to avoid any pressure on the globe. Once the eye is visualized, the integrity of the globe and visual acuity must be assessed immediately. Signs such as an abnormal anterior chamber depth, an irregular pupil, or blindness indicate a ruptured globe until proven otherwise, and an emergent ophthalmology referral is indicated. An eye shield should be placed as soon as a globe injury is suspected. If the globe and vision are preserved, signs of hyphema and blowout fracture should be sought. A complete slit lamp examination and a funduscopic examination is facilitated by dilation with tropicamide 1% 1 drop (phenylephrine 2.5% 1 drop in noncaucasians with brown eyes). Particular attention should be paid to check for abrasions, lacerations, foreign bodies, hyphema, pupillary injury, iritis, and lens dislocation. A CT of the orbit is the ED test of choice to confirm the presence of ruptured globe and orbital fractures, but sensitivity can be as low as 56% for occult globe injury; therefore, the involvement of an ophthalmologist is mandatory for possible surgical exploration in high-risk or suspicious cases. Traumatic iritis in the absence of a corneal injury can be treated with prednisolone acetate 1% 1 drop every 6 hours and cyclopentolate 1% 1 drop every 8 hours. The care of the blunt trauma eye patient should be discussed with an ophthalmologist, and the patient should follow-up with the ophthalmologist within 48 hours even if no significant injuries are initially found.

Hyphema

A hyphema is the presence of blood in the anterior chamber and often is a sign of significant trauma. It also can occur spontaneously in sickle cell patients and in patients with coagulopathies. Sight-threatening increases in IOP can occur. In all hyphemas, emergent evaluation by an ophthalmologist is indicated. The patient should be placed either upright or HOB to 30° to 45° to allow the blood to settle inferiorly, which allows faster improvement of vision and facilitates assessment of the hyphema size and posterior pole. A protective eye shield should be in place, except during examination and medication administration. After ruptured globe is excluded, the patient should be evaluated for other eye injuries and treated appropriately. After ruptured globe is excluded, IOP should be measured. A 2001 Cochrane systematic review concluded found no evidence of improved visual acuity with traditional treatments of traumatic hyphema, including antifibrinolytic agents, corticosteroids, cycloplegics, miotics, aspirin, conjugated estrogens, patching, elevation of head, and bed rest. However, antifibrinolytic agents (aminocaproic acid or tranexamic acid) were associated with decreased incidence of rebleeding, but these agents should only be administered by an ophthalmologist. Because of the risk of rebleed in 3 to 5 days and the potential necessity of surgical intervention, any disposition decisions should be made by an ophthalmologist at the bedside, regardless of the size of the hyphema.

Blowout Fractures

Orbital blowout fractures commonly involve the inferior wall and medial wall. The resultant entrapment of the inferior rectus muscle may cause restriction of movement, with a resultant diplopia on upward gaze. Other signs include paresthesia in the distribution of the infraorbital nerve and subcutaneous emphysema, particularly when sneezing or blowing the nose. Plain radiographs are of little utility in these patients; therefore, if a blowout fracture is suspected, CT of the orbit with 1.5-mm cuts should be performed, with additional studies as indicated. Because of the high incidence of associated ocular trauma (30%), an aggressive effort should be made to exclude associated injuries. Antibiotic prophylaxis (cephalexin 250 milligrams to 500 milligrams PO 4 times daily for 10 days) is recommended due to sinus involvement. Isolated blowout fractures, with or without entrapment, require early referral to an ophthalmologist.

Penetrating Trauma or Ruptured Globe

Globe penetration or rupture is a catastrophic injury that must be identified immediately. Suggestive findings include a severe subconjunctival hemorrhage, shallow or deep anterior chamber as compared with the other eye, hyphema, teardrop-shaped pupil, limitation of extraocular motility, extrusion of globe contents, or a significant reduction in visual acuity. A penetrating injury should be suspected when the history of a high-speed foreign body (eg, the patient was hammering or grinding without eye protection) or a penetrating injury in proximity of the orbit is present. A bright-green streaming appearance to fluorescein instilled into the tear layer (Seidel test) is pathognomonic, although it may be absent if the wound has sealed. Therefore, the presence of an abrasion with this mechanism does not rule out a penetrating injury. Once a globe injury is suspected, any further manipulation or examination of the eye must be avoided. In such cases, the patient should be placed upright and kept npo. A protective metallic eye shield should be put in place, and a first generation cephalosporin should be administered (cefazolin 1 gram IV) with an antiemetic (to prevent Valsalva). Tetanus status should be updated. Studies have shown plain x-rays are a poor screen for injury or foreign body in these cases. A CT of the orbit is the ED test of choice to confirm the presence an orbital foreign body or a ruptured globe. However, as noted above, even CT sensitivity can be low for occult globe injury; therefore, an ophthalmologist should be called immediately if a globe rupture or a penetrating injury is strongly suspected.

Chemical Ocular Injury

Acid and alkali burns are managed in a similar manner. The eye should be flushed immediately at the scene and sterile normal saline or Ringer lactate irrigation solution should be continued in the ED immediately upon arrival (even before visual acuities or patient registration) until the pH is normal (7.0 to 7.4). A topical anesthetic and a Morgan lens are used in this procedure. After the first 2 L of irrigation, the pH may be checked in the lower cul-de-sac with litmus paper or the pH square on a urine dipstick 5 to 10 min after ceasing irrigation (to allow time for equilibration). Required irrigation volumes to reach normal pH may exceed 8 to 10 L, depending on the caustic substance. A persistently abnormal pH should prompt removal of any crystallized particles in the fornices with a moistened cotton-tipped applicator. Once the pH is normal, the fornices should be inspected and the eyelids everted to look for any residual particles and reswept with a moistened cotton-tipped applicator to remove them and any necrotic conjunctiva. The pH should be rechecked in 10 min to make sure that no additional corrosive is leaching out from the tissues. A thorough slit lamp examination, with lid eversion, should be done to assess the amount of damage and any associated injuries. IOP should be measured because it can become elevated with significant burns. A cycloplegic (homatropine 5% or cyclopentolate 1%) 1 drop 3 times daily will alleviate ciliary spasm, and erythromycin 0.5% ophthalmic ointment applied every 1 to 2 hours while awake should be prescribed. Most patients will require opioid pain medications. Tetanus should be updated. If there are signs of a severe injury, such as a pronounced chemosis, conjunctival blanching, epithelial defect, corneal edema or opacification, or increased IOP, the patient should be seen in the ED by an ophthalmologist. Certain specialized burns, such as those due to hydrofluoric acid, lye, or concrete, also should be seen immediately. Otherwise, a telephone consult with the ophthalmologist to arrange close follow-up within 24 hours should be obtained for all burns.

Cyanoacrylate (Super Glue or Crazy Glue) Exposure

Cyanoacrylate glue easily adheres to the eyelids and corneal surface. Its primary morbidity stems from corneal injuries from the hard particles that form. Initial manual removal is facilitated by heavy application of erythromycin 0.5% ophthalmic ointment, with special care to avoid damaging underlying structures. After the easily removable pieces are removed, the patient should be discharged with erythromycin 0.5% ophthalmic ointment to be applied 5 times a day to soften the remaining glue. Complete removal of the residual glue can be accomplished by the ophthalmologist at a follow-up visit within 24 hours. Serious injury from this exposure is rare.

Acute Angle Closure Glaucoma

Acute angle closure glaucoma classically presents with eye pain or headache, cloudy vision, colored halos around lights, and the patient may be vomiting. Physical examination may reveal conjunctival injection, cornal clouding, (see Fig. 149-1) a fixed mid-dilated pupil, and increased IOP of 40 to 70 mm Hg (normal range, 10 to 20 mm Hg). Nausea and vomiting are also common. Sudden attacks in patients with narrow anterior chamber angles can be precipitated in movie theaters, while reading, and after ill-advised use of dilatory agents or inhaled anticholinergics or cocaine. All cases require immediate ophthalmologic consultation as recent data suggest that immediate argon laser peripheral iridoplasty (ALPI) or anterior chamber paracentesis may be first-line treatments in these patients. Simultaneous to the ophthalmology consult, attempts to decrease the IOP (Table 149-3) should begin immediately. Medications to administer include: timolol 0.5%, apraclonidine 1.0%, and PO acetazolamide in the absence of contraindications (eg, acetazolamide is contraindicated in sickle cell and sulfa allergic patients). If IOP is greater than 50 mm Hg, if vision loss is severe, or if the patient cannot tolerate PO then IV acetazolamide should be considered. If IOP does not decrease and vision does not improve in 1 hour, mannitol should be given. Pilocarpine 1% to 2% 1 drop every 15 min for 2 doses in the affected eye and pilocarpine 0.5% 1 drop in contralateral eye may be given once the IOP is below 40 mm Hg as long as the patient has a natural lens in place. Pilocarpine is contraindicated in aphakic and pseudophakic patients or when there is mechanical closure of the angle. Some experts recommend giving pilocarpine immediately upon diagnosis. Symptoms of pain and nausea should be treated, and the IOP should be monitored hourly. Subsequent treatment decisions and disposition of the patient should be made by an ophthalmologist at the bedside.

Optic Neuritis

Optic neuritis (ON) refers to inflammation at any point along the optic nerve and presents with acute vision loss, with a particular reduction in color vision. It is strongly associated with multiple sclerosis (MS). It is often painful (> 50%), especially with extraocular movements. A decrease in color vision can be diagnosed by the “red desaturation test.” During this test, the patient looks at a dark red object with 1 eye, and then the color vision in the other eye is tested. The affected eye will see the object as pink or light red. An afferent pupillary defect (APD) often also can be detected, and visual field defects may be present. In anterior optic neuritis, the optic disc appears swollen (papillitis); there are no ophthalmoscopic findings in retrobulbar cases. An ophthalmologist should direct evaluation and treatment. IV steroids, followed by oral steroids have been shown to accelerate visual recovery and temporarily reduce the risk of developing MS, but oral steroids alone actually increase the rate of ON reoccurrence. A new diagnosis of optic neuritis should prompt a workup for MS.

Central Retinal Artery Occlusion

Central retinal artery occlusion presents as a sudden, painless, severe monocular loss of vision, often associated with a history of amaurosis fugax. Occlusion of the central retinal artery will cause complete visual loss, whereas arterial branch obstruction will cause abrupt loss of a partial visual field. Classic signs include nearly complete or complete vision loss (94% with counting fingers to light perception only), a marked afferent pupillary defect (APD), superficial opacification or whitening of the retina in the posterior pole, and a bright red macula “cherry red spot.” Segmentation of the blood column in the arterioles (“boxcarring”) sometimes can be seen. A thorough evaluation to uncover the embolic source (commonly carotid or cardiac) is required, and giant cell arteritis must be excluded. An ophthalmologist should be contacted immediately once the diagnosis is made. In the past, digital massage, acetazolamide, and timolol have been recommended, but evidence to support these interventions is sparse. Therefore, management should be directed by an ophthalmologist per institutional protocols.

Central Retinal Vein Occlusion

Central retinal vein occlusion causes acute, painless monocular vision loss. Examination shows optic disc edema, cotton wool spots, and retinal hemorrhages in all 4 quadrants. This pattern is described as “blood-and-thunder fundus.” IOP should be measured. There is no immediate treatment for central retinal vein occlusion, but predisposing drugs (eg, oral contraceptives or diuretics) should be discontinued. An ophthalmology consult should be obtained.

Retinal Detachment and Floaters

Patients who experience sudden change in their vision due to retinal detachment or “floaters” in their visual field usually seek medical attention in the ED. Bilateral complaints are almost always intracranial and may be due to migraine headaches. Monocular symptoms are usually due to disorders in the symptomatic eye. Retinal detachment typically presents as a sudden dark veil or curtain-like defect in the patients visual field, affecting the symptomatic eye. Presumptive diagnosis can be made by bedside ultrasound (Fig. 149-2). Urgent ophthalmologic consultation is necessary for indirect ophthalmoscopic evaluation, and potentially laser surgery. In contrast, new “floaters” which are small particles of vitreous gel appearing to the patient as small hazy opacities, need no immediate attention, and can be followed up by the ophthalmologist in the office within 1 week.

Temporal Arteritis (Giant Cell Arteritis)

Temporal arteritis (TA) is a systemic vasculitis that can cause a painless ischemic optic neuropathy. Patients are typically women older than 50 years, often with a history of polymyalgia rheumatica. Associated symptoms include vision changes, headache, jaw claudication, scalp or temporal artery tenderness, fatigue, fever, sore throat, URI symptoms, and anorexia. One-third of cases have associated neurologic events such as transient ischemic attacks or stroke. An APD is frequently present, and funduscopic examination may show flame hemorrhages. A sixth cranial nerve palsy may occur. When TA is suspected, a sedimentation rate (ESR) and C-reactive protein (CRP) should be ordered; both are elevated in TA, with the CRP the more sensitive test. Most biopsy-proven cases have an ESR in the range of 70 to 110 mm/h. If TA is not treated, bilateral vision loss can develop. Therefore, if there is strong suspicion of TA or vision loss is present, the patient should be admitted for methylprednisolone 250 milligrams IV every 6 hours. For less suspicious patients with no vision loss, they may be discharged with prednisone 80 to 100 milligrams/d PO with close follow-up. Steroids should not be delayed pending results of a biopsy. Antiulcer medications should be prescribed to be given with systemic steroids.