Management of common emergencies presenting to Eye Clinic

According to previous surveys locally and nationally, the majority of patients presenting as an emergency to the Eye Clinic have one of the following diagnoses:

• Conjunctivitis
• Corneal abrasion
• Corneal or conjunctival foreign body
• Herpes simplex
• Herpes zoster ophthalmicus
• Flashes and floaters

You should ensure that you are prepared for the common and rare emergency conditions. The management of some of these is covered in the following sections. Please complete a pre-printed letter or dictate a letter for each patient.

Conjunctivitis:

Bacterial conjunctivitis is usually self-limiting but antibiotics will probably shorten the symptomatic period. (See Clinical Evidence) Treat bacterial conjunctivitis with reasonably broad spectrum antibiotics such as Chloramphenicol or Ofloxacin . Viral conjunctivitis is usually a clinical diagnosis and swabs for viral PCR are often unnecessary.
Chlamydial conjunctivitis should be considered particularly in longer duration cases in the age group 16-30 where the redness is largely unilateral and lymphadenopathy is palpable or tarsal conjunctival follicles are seen. Swab for Chlamydia is important, and refer to GUM for treatment & contact tracing if positive.

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Corneal Abrasion:

• Evert lids to exclude subtarsal foreign bodies
• Chloramphenicol eye ointment 1% 3 x day for 5 days or until symptoms resolved
• Cycloplegic if warranted e.g. cyclopentolate 1% stat
• Pad according to patient preference
• Discharge from clinic but warn of small risk of recurrent epithelial erosion
• Contact lens wearers should still be reviewed by ophthalmologist within 18 hours

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Corneal or conjunctival foreign body:

• History to assess risk of penetrating injury
• Evert lids to exclude sub-tarsal foreign bodies
• Look for entry wound if high risk of penetrating injury
• X-ray of orbits rarely necessary
• Remove foreign body & "rust ring" at first visit
• Treatment and follow-up as for abrasion
• If deep foreign body or a suspicion of Intra-Ocular Foreign Body, do ocular ultrasound (“B-scan”) and request x-rays (eg looking up and looking down orbital X-rays) if needed and refer to senior to consider removal in theatre.

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Herpes simplex

This is often over-diagnosed and all new cases should be confirmed with a swab; recurrent cases should also be swabbed if no previous swab positive
Common acute manifestations include blepharo-conjunctivitis, epithelial disease, stromal disease (disciform keratitis), uveitis.

Management - NB: Ganciclovir (Virgan) eye gel must be given with full consideration of the guidelines on pregnancy

• Blepharo-conjunctivitis: Ganciclovir (Virgan) 0.15% eye gel 5x daily to affected eye(s) until symptoms resolve then 3x a day for 1 week. Review 14 days.
• Epithelial disease: Ganciclovir (Virgan) 0.15% eye gel 5x daily to affected eye(s) until symptoms resolve then 3x a day for 1 week. Review 14 days.
• Stromal disease (disciform keratitis): Ganciclovir (Virgan) 0.15% eye gel 5x daily to affected eye(s) until symptoms resolve then 3x a day for 1 week, topical cycloplegic if required and topical steroids, e.g. betamethasone 0.1% 5x daily if there is no epithelial disease. Review 7 days. If there is a clear history of recurrent stromal disease and/or the patient's old notes are present, consider starting oral Aciclovir 400mg twice daily if patient not on this already. Refer cornea clinic.
• Keratouveitis: Topical Ganciclovir (Virgan) 0.15% 5x daily to affected eye(s)  until symptoms resolve then 3x a day for 1 week, topical cycloplegic and if there is no epithelial disease topical steroids; e.g. betamethasone 0.1% 5x daily. Review 5-7 days.
• Hypertensive uveitis: As for Stromal disease (disciform keratitis) plus topical anti-glaucoma agents as dictated by the level of the intra-ocular pressure. Review 1-7 days depending on severity of uveitis/IOP

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Herpes zoster ophthalmicus

If a patient develops a rash suggestive of Herpes Zoster Ophthalmicus there is no point in an ophthalmologist seeing the patient initially as intra-ocular manifestations of Herpes Zoster are uncommon in the first week. The referring clinician can, if seeing the patient within 72 hours of onset of rash, give systemic antiviral treatment e.g. aciclovir 800mg orally 5x daily for 1 week.
An eye clinic appointment should be arranged 7 days after the appearance of the first vesicle. If a patient attends eye clinic in the first week of the disease process, they need to be reviewed again the next week to ensure there is no uveitic complication hence the unhelpful first visit should be avoided where possible.
Common acute manifestations include blepharo-conjunctivitis, epithelial disease and hypertensive uveitis. Less common acute features include (Epi)scleritis, scleritis, nummular keratitis, retinitis and neurological disease.
Management:

• For all cases, check intra-ocular pressure and perform dilated fundus examination. .
• Blepharo-conjunctivitis: Treatment not always necessary, but if required topical antibiotics (eg chloramphenicol ointment 1% four times a day for 1week).
• Corneal epithelial disease (dendritiform lesions): Topical lubricants. No proven benefit of topical antivirals. Consider topical steroids if any sign of disciform keratitis. Uveitis: Treat according to severity. Topical steroid +/- cycloplegia. NB. Check intra-ocular pressure and anticipate a longer period of tapering steroid (over at least 2 months as rebound uveitis is much more common than in idiopathic acute anterior uveitis)

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Flashes & floaters:

• Check intra-ocular pressure then dilate both eyes. Look for:
  • Tobacco dust
  • Vitreous haemorrhage
  • Weiss ring (absence suggest no or partial posterior vitreous detachment)
• The gold standard examination is to check fundus with indirect ophthalmoscope and indentation, get senior review if unable to examine with indirect ophthalmoscope.
• If retinal tear found, immediate treatment required. If comprehensive laser retinopexy is NOT felt to be achieved with a slit lamp mounted laser then this should be discussed with a Vitreo-Retinal specialist within 24 hours to arrange indirect laser or cryotherapy. If a comprehensive laser retinopexy can be achieved then it should be reviewed by the clinician doing the laser after 2 weeks to assess adequacy of treatment.
• If posterior vitreous detachment related vitreous haemorrhage, or tobacco dust found, with no identifiable tear, a B-scan should be done by an ophthalmologist if the view is limited & discuss with a Vitreo-Retinal specialist within 24 hours
• Neovascular causes of vitreous haemorrhage where PRP (Panretinal Photocoagulation) laser has previously been performed should be reviewed in a Medical Retina specialist clinic in 3-4 weeks. If no previous PRP then Vitreo-Retinal review in 2 weeks should be arranged for consideration of vitrectomy.
• If uncomplicated posterior vitreous detachment is fully examined and documented - do NOT follow them up; advise patient about symptoms of retinal detachment, likelihood of similar pathology in fellow eye, document you have done this and provide patient with a printed letter/advice and discharge

Any sub retinal macular haemorrhage to be seen by Vitreo-Retinal specialists within one week for consideration of vitrectomy