Author: William Spackman, Adam Booth / Editor: Liz Herrievan / Codes: OptC3, OptC4, OptC5, OptP2, SLO1, SLO4 / Published: 13/05/2025
Editor’s intro: This fab four-part blog has been written for us by an ophthalmology registrar. The aim is to highlight the eye conditions we ED folk should be aware of, particularly those we need to refer asap. Some of the slit-lamp examination findings described might elude some of us (me, at least) in many cases, but don’t let that put you off! I’ve also Googled some of the more unfamiliar terms so you don’t have to….
Introduction
There are a limited number of true ophthalmic emergencies, but it is important for emergency clinicians to be aware of ophthalmic conditions where immediate action needs to be taken. In many of the conditions discussed in this blog, prompt recognition and management can be sight-preserving and, in certain cases, life-preserving. This blog aims to guide emergency clinicians in the assessment and management of some of the most important emergency ophthalmic presentations.
The Swollen Lid
The swollen lid is a common presentation to the emergency department and has a wide differential from benign to serious pathology. This section looks primarily at pre-septal and orbital cellulitis.
Pre-septal and Orbital Cellulitis
It is not uncommon for the terms pre-septal and orbital cellulitis to be used interchangeably but there is an important difference between them. The septum is fibrous tissue that extends from the orbital periosteum and forms the tarsal plate. The septum acts as a barrier between the superficial lid tissues and the orbit.1 Pre-septal cellulitis is confined to the superficial lid tissue whereas orbital cellulitis involves tissue posterior to the tarsal plate.1 Both are more common in children.
Orbital Cellulitis
Orbital cellulitis may be caused by direct post-septal infection following trauma or surgery. It may also be caused by secondary spread from adjacent structures including pre-septal cellulitis, sinusitis, dental infections and dacryocystitis (infection or inflammation of the lacrimal sac).1
Orbital cellulitis presents with lid swelling and erythema with additional signs of orbital involvement including restricted ocular motility, proptosis and optic nerve dysfunction; reduced visual acuity, reduced colour vision, a relative afferent pupillary defect and/or a swollen optic nerve.1 Orbital cellulitis may cause life threatening systemic complications including meningitis, cerebral abscess and cavernous sinus thrombosis.1
Patients with orbital cellulitis should be admitted and managed with a multidisciplinary approach between ophthalmology, ENT and paediatrics if appropriate. Imaging, usually CT of the brain/orbits and sinuses, should be arranged urgently. The patient should be managed with intravenous antibiotics. If an abscess is identified either within the orbit or adjacent sinuses, ENT may opt to drain the abscess, particularly if there is evidence of optic nerve dysfunction.
Periorbital Cellulitis
Periorbital cellulitis most commonly presents in children, predominantly those under 5.1 It will typically present with a unilateral oedematous and erythematous lid and there may be associated fever or malaise.1 Importantly, there should be normal optic nerve function, normal ocular motility and no proptosis.
Patients can usually be managed with oral antibiotics but in young or systemically unwell patients, admission and IV antibiotics should be considered in consultation with the paediatric team.1 Daily review should take place to ensure they are responding to treatment and there is no progression to orbital cellulitis. Children do not have a fully developed orbital septum and so are at particular risk of progression to orbital cellulitis. Caution should therefore be taken in younger patients.1
Other Causes
Other causes of a swollen lid include:
- Herpes zoster ophthalmicus
- Allergic or viral conjunctivitis
- Trauma
- Thyroid eye disease
- Orbital masses
Ocular Trauma
Ocular trauma can be a troublesome presentation, but it is important to be able to filter out immediately sight-threatening pathology so that prompt treatment can be initiated.
Orbital Compartment Syndrome
Orbital compartment syndrome (OCS) is an ophthalmic emergency and one of very few conditions whereby immediate treatment can be sight-saving as delay in treatment will lead to irreversible vision loss.
The orbit is a fixed space with the orbital bones and eyelids forming the borders. An increase in mass within the orbit will therefore increase the pressure within this space.2 This increasing pressure within the orbit will compress the vessels supplying the optic nerve, quickly leading to ischaemia and an irreversible optic neuropathy.2
Patients usually present following significant trauma and thus history may be limited. Patients may complain of pain, reduced vision or double vision.2 In OCS there is usually significant periorbital bruising, proptosis and significant limitation in ocular motility.2 OCS will cause an acute reduction in visual acuity, a RAPD and reduced colour vision. Orbital compartment syndrome is a clinical diagnosis and treatment should not be delayed to obtain radiological confirmation.
Immediate action is required to decompress the orbit. This is done by performing a lateral canthotomy and inferior cantholysis. If this fails to decompress the orbit then a superior cantholysis should be performed. This procedure effectively releases the anterior border of the orbit and thereby decompresses the orbit. If performed promptly then optic nerve dysfunction may be reversible.
Globe Rupture and Laceration
The term globe rupture refers to a full thickness injury to the cornea or sclera as a result of blunt trauma.3 Globe laceration on the other hand is a full thickness injury from sharp trauma.3
Gross signs of globe trauma include a ‘peaked pupil’ (that points towards the sight of penetration), iris incarceration in the cornea and evidence of dark choroidal tissue protruding through the sclera.4 With slit lamp examination, conjunctival, scleral and corneal lacerations may be seen. Care should be taken to look for iris transillumination and focal lens opacities suggestive of penetrating injury. Fundal examination is important to look for intraocular foreign bodies and sequalae of blunt trauma such as vitreous haemorrhage, commotio retinae and retinal tears or detachment.
It is important to note that where globe rupture is suspected, immediate specialist input should be sought as examination in a manner that puts pressure on the globe can cause further problems.
Pending surgery, patients with an open globe injury should be kept nil by mouth and have a plastic shield placed over the orbit to prevent the patient from rubbing their eye. They should also be given a broad-spectrum oral antibiotic such as moxifloxacin to prevent secondary infection. It is important to determine if the patient is up to date with tetanus immunisations and manage appropriately if not.4
The surgical intervention for penetrating eye injury is beyond the scope for this article but the general principles are to close the eye at primary surgery and consider secondary surgery for ongoing treatable pathology.4
Chemical Injury
The overarching principle of chemical injuries is to treat first and seek a history and detailed examination second. Patients presenting to the emergency department with ocular chemical injury should ideally have a pH check and then irrigation should be started immediately. The affected eye should be anaesthetised with a topical anaesthetic such as proxymetacaine and irrigated with a minimum of 1 litre of 0.9% normal saline through an IV giving set.5 The cornea, conjunctiva, fornices and everted lids should be irrigated until the PH is 7. It is important to recheck the pH every 15 minutes for at least an hour after irrigation to ensure the PH does not rise again as chemical can continue to seep out of the tissues.5
After successful irrigation, one can then take a detailed history and carefully examine the patient. Examination findings to note include corneal clarity and visibility of the underlying iris. Fluorescein should be instilled to look for epithelial defects in the conjunctiva and cornea. A slit lamp examination is performed to examine more closely for limbal ischaemia, corneal haze, anterior chamber inflammation and intraocular pressure abnormalities.
The management for chemical injuries acutely depends on severity. Specialist input should be sought to guide this after irrigation has been completed (plus take a look at Toxbase or speak to NPIS). Treatment of moderate to severe chemical injury includes intensive topical steroid, topical antibiotics, vitamin C supplementation topically and/or orally and topical lubrication.5
Conclusion
The role of the emergency clinician is to be able to recognise and distinguish serious ophthalmic pathology, initiate immediate investigation and management if appropriate and make a timely referral to ophthalmology. As discussed, prompt recognition of certain ophthalmic conditions is of great importance. Having a structured history and examination pattern will help narrow the differential considerably and ease discussion and referral to the ophthalmic team. Hopefully this blog will act as an aide to recall the key considerations of varying presentations and give clinicians confidence in assessing patients with emergency ophthalmic presentations.
Part 4 – Flashes, Floaters and Double Vision
References
- Denniston AKO, Murray PI, editors. Oxford handbook of ophthalmology. 4th ed. Oxford University Press; 2018.
- American Academy of Ophthalmology. Orbital compartment syndrome – EyeWiki. Eyewiki.org. 2024 May 19 [accessed 2024 Nov 19].
- Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004 Feb;27(2):206-10.
- American Academy of Ophthalmology. Ruptured globe – EyeWiki. Eyewiki.org. 2024 Sep 19 [accessed 2024 Nov 19].
- Corbett MMC, FRCOphth MDF. Chemical injuries of the ocular surface. Rcophth.ac.uk. [accessed 2024 Nov 19].