Common Emergencies Presenting to Eye Clinic - Management of

Publication: 01/01/2004  
Last review: 07/06/2017  
Next review: 01/06/2020  
Standard Operating Procedure
CURRENT 
ID: 520 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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

See: BMJ 1986;292:188-190
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.

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Conjunctivitis:

Bacterial conjunctivitis is usually self-limiting but antibiotics will probably shorten the symptomatic period. (See Clinical Evidence) Treat bacterial conjunctivitis with broad spectrum antibiotics such as Fusidic acid, Chloramphenicol electronic Medicines Compendium information on Chloramphenicol or Ofloxacin electronic Medicines Compendium information on Ofloxacin . Viral conjunctivitis is usually a clinical diagnosis and swabs for viral PCR are often unnecessary.

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Corneal Abrasion:

  • Evert lids to exclude subtarsal FB
  • Occ Chloramphenicol electronic Medicines Compendium information on Chloramphenicol 1% tds for 5 days or until symptoms resolved
  • Cycloplegic if warranted e.g. g. cyclopentolate 1% stat
  • Pad according to patient preference
  • Discharge from clinic but warn of small risk of recurrent epithelial erosion

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Corneal or conjunctival foreign body:

  • History to assess risk of penetrating injury
  • Evert lids to exclude sub-tarsal FB
  • 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 FB or a suspicion of IOFB, refer to senior to consider removal in theatre.

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Herpes simplex

  • Common acute manifestations include blepharo-conjunctivitis, epithelial disease, stromal disease (disciform keratitis), uveitis.
  • Management
  • Blepharo-conjunctivitis: Topical Aciclovir electronic Medicines Compendium information on Aciclovir 3% 5x daily. Review 14 days.
  • Epithelial disease: Topical Aciclovir electronic Medicines Compendium information on Aciclovir 3% 5x daily for 10 days. Review 14 days.
  • Stromal disease (disciform keratitis): Topical Aciclovir electronic Medicines Compendium information on Aciclovir 3% 5x daily 2 weeks, topical cycloplegic if required and topical steroids, eg 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 electronic Medicines Compendium information on Aciclovir 400mg bid if patient not on this already. Refer cornea clinic.
  • Keratouveitis: Topical Aciclovir electronic Medicines Compendium information on Aciclovir  3% 5x daily, topical cycloplegic and if there is no epithelial disease topical steroids; eg betamethasone 0.1% 5x daily. Review 5-7 days.
  • Hypertensive uveitis: As for disciform keratitis plus topical anti-glaucoma agents as dictated by the level of the IOP. Review 1-7 days depending on severity of uveitis/IOP

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Herpes zoster ophthalmicus

  • 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 IOP and perform dilated fundus examination.
  • If presentation within 72 hours of onset of rash, give systemic antiviral treatment e.g. acyclovir 800mg orally 5x daily or other similar drug for 1 week.
  • Blepharo-conjunctivitis: Treatment not always necessary, but if required topical antibiotics qid x 1wk. Review 1 week.
  • Epithelial disease (dendritiform lesions): Topical lubricants. No proven benefit of topical antivirals. Consider topical steroids. Review 1 week.
  • Uveitis: Treat according to severity. Topical steroid +/- cycloplegia. NB. Check IOP.

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Flashes & floaters:

  • Check IOP then dilate both eyes. Look for:
    • Tobacco dust
    • Vitreous haemorrhage
    • Weiss ring (absence suggest no or partial PVD)
  • The gold standard examination is to check fundus with indirect ophthalmoscope and indentation (RCOphth outcome CA10 target year of achievement year 2), get senior review if unable to examine with indirect.
  • If retinal tear found, immediate treatment required. If comprehensive laser is NOT felt to be achieved then this should be discussed with VR 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 PVD related vitreous haemorrhage, or tobacco dust found, with no identifiable tear, a B-scan should be obtained if the view is limited & discuss with VR within 24 hours
  • Neovascular causes of vitreous haemorrhage where PRP has previously been performed should be reviewed in MR clinic in 3-4 weeks. If no previous PRP then VR review in 2 weeks should be arranged for consideration of vitrectomy.
  • If uncomplicated PVD 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

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Provenance

Record: 520
Objective:
Clinical condition:
Target patient group: All
Target professional group(s): Secondary Care Doctors
Adapted from:

N/A


Evidence base

BMJ 1986; 292:188-190, Clinical Evidence, 10th Issue, BMJ Publishing Group

Document history

LHP version 1.0

Related information

Not supplied

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