Is My Eye Problem An Emergency?

From: "The Eye of A Surgeon", by Dr Cynthia J MacKay

Some eye conditions are true emergencies, and it is vital that you seek eye care immediately. Some eye conditions need to be seen promptly, but not on an emergency basis. Some eye conditions are harmless. How do you tell which is which?

• Rule number one: See your ophthalmologist as soon as possible if you ever experience PAIN or LOSS OF VISION in an eye.
• Rule number two: If one of your eyes has been struck forcefully or penetrated, seek care even if the eye is comfortable and the vision is unchanged.
• Rule number three: If any chemical, such as cleaning solutions or garden products, gets into your eye, immediately flush that eye for 15 minutes with running tap water, before you seek eye care. Alkaline solutions (lye, drain cleaner) are even worse than acid solutions.

If you do not have an ophthalmologist, or if you are away from home, find a teaching hospital that has a training program in ophthalmology, go to their emergency room, and ask to see the eye resident on call.

This chapter describes several examples of each type of eye problem.

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TRUE EYE EMERGENCIES

1. Angle closure glaucoma

Symptoms:

• SEVERE eye pain.
• Decreased vision, with halos around lights.
• You feel nauseated, and might even vomit.
• The eye is red, and your cornea is grey-white instead of clear.

Treatment:

• Drops and pills will lower your eye pressure and constrict your pupil.
• A laser iridotomy will be performed as soon as your cornea clears (for further details, see glaucoma chapter).

Why is this an emergency?

• If there is high pressure inside your eye, it will go blind quickly unless the pressure is returned to normal fast.

2. Retinal tear/detachment

Symptoms:

• Floaters (bits of debris that fly around like gnats).
• Brief, strong flashes of light, which are especially obvious whenever you move your eye, and when you are in dim light.
• A persistent blank area in your field of vision.

Treatment:

• If your retina is only torn, and not detached yet, you can be treated as an outpatient, either with laser or with cryopexy (freezing), depending on the location and size of your tear.
• If your retina is truly detached, your ophthalmologist will chose among several different treatment options, depending on the type of detachment, your age, and whether or not you have had previous cataract surgery.
• You might have an outpatient procedure called pneumatic retinopexy, or one of several inpatient procedures, such as scleral buckle or vitrectomy (see retina chapter).

Why is this an emergency?

• If your detached retina is repaired early, before your macula becomes detached, you will retain normal sight.
• If your macula has been detached for more than 24 hours, you will probably never again have 20/20 vision, even if your surgery is “successful”, unless you are very young, or very lucky.

3. Central retinal artery occlusion

Symptoms:

• Sudden, painless, non-progressive, complete or near-complete loss of vision in one eye.
• The eye looks normal.
• You feel well.

Treatment:

• No treatment is effective if your occlusion is more than 24 hours old.
• If you have lost your vision within the last 24 hours, immediately start rebreathing into a paper bag.
• Get help immediately. Your doctor will lower the pressure in your eye with eye massage, drops and pills. He may also remove some aqueous from your anterior chamber.
• He will arrange for you to be worked up, with some blood tests, and some studies of your heart and carotid artery.

Why is this an emergency?

• Your retina, like your brain, dies quickly if its blood supply is lost. Your sight can only be saved if your artery is re-opened quickly.

4. Inflammation of the artery that feeds your optic nerve (this is called “ischemic optic neuropathy”)

Symptoms:

• Sudden, painless, non-progressive vision loss on one eye.
• The eye looks normal.
• You feel poorly. You have headaches, jaw pain when you chew, scalp tenderness when you comb your hair, and aches in your muscles and joints.

Treatment:

• Your doctor will immediately order some blood tests, including an ESR.
• Your will almost certainly be treated immediately with high-dose steroids, both intravenously and by mouth.
• You will need to take steroids by mouth, at tapering doses, for at least 3 months and possibly for as long as a year or more.
• Your doctor will schedule you for a biopsy of the artery in your temple within the next day or two.

Why is this an emergency?

Your headache and joint pain are caused by a disease called Giant-Cell Arteritis. All the arteries in your head are at risk. If the inflammation is not immediately treated with steroids, your other eye may also lose its sight, or you may suffer a stroke.

5. Wet Macular Degeneration

Symptoms:

• Blurred vision.
• Distortion of straight lines, e.g. window blinds or floor tiles.
• Small blank spots around the centre of your sight.

Treatment:

• See a retina specialist promptly.
• You will have a dye test called a fluorescein angiogram.
• You will be treated either with a laser, or with a drug that inhibits blood vessel growth (Lucentis or Avastin), which will be injected directly into your eye. (See retina chapter)

Why is this an emergency?

Abnormal blood vessels are growing underneath your retina. If they bleed, you will have irreversible scarring, and your sight cannot be restored.

6. Uveitis

Symptoms:

• Red eye(s)
• Painful and sensitive to light
• Blurred vision
• Dark spots floating around
• Flashes of light

Treatment:

• See an ophthalmologist immediately.
• Dilation and anti-inflammatory drops.

Why is this an emergency?
Uveitis is a serious inflammation inside the eye that can cause glaucoma or cataract if not treated. Most of the time it is not associated with disease elsewhere in the body but it may sometimes be associated with infections such as Lyme Disease, or inflammatory diseases such as rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, lupus or herpes.

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NEED TO BE SEEN PROMPTLY

1. Corneal ulcer

Symptoms

• Your eye feels as if there is sand in it.
• It hurts when you look at bright light.
• You have a discharge.
• Your eye is slightly red.
• Your vision is slightly blurry.
• These symptoms can also be caused by a corneal abrasion or a corneal foreign body. If you have an ulcer, you can often see a tiny white spot on your cornea if you look in the mirror.

Treatment

• Corneal ulcers are small dead spots on your cornea that have become infected.
• Bacteria are the number one cause of corneal ulcers. People who wear contact lenses are especially at risk, especially those who over-wear their lenses, do not sterilize them as directed, or sleep or swim in them.
• Standard treatment for bacterial ulcers is to take antibiotic drops every hour while awake for a day or two, then 4 times a day until told to stop.
• Viral corneal ulcers are usually caused by the Herpes simplex virus. After you have a herpes infection as a child, this virus remains throughout your life in the nerves in your brain. Occasionally, it can reactivate, and grow down the nerves to infect the cornea. This virus also causes cold sores on your lips.
• Standard treatment for a Herpes simplex ulcer is an anti-viral drop, such as Viroptic, taken every hour for the first day, then 4 times a day until your doctor tells you it is safe to stop.
• Rarely, ulcers may be caused by fungi or protozoa. These are more serious, and more difficult to treat

2. Conjunctivitis

Symptoms:

• Red, irritated eye(s).
• Swollen lids.
• Discharge.

Treatment:

• If your discharge is thick and creamy, your conjunctivitis is usually due to a bacterium. Standard treatment is antibiotic drops (for example, Sulfacetamide, Polytrim, or Vigamox), four times a day for a week.
• If your discharge is watery, and there are tender lumps in front of your ears, your conjunctivitis is usually due to a virus. People who have an upper respiratory infection will often get some form of conjunctivitis.
• Antibiotics are useless, and can be harmful, if you have viral conjunctivitis. Use artificial tears and warm compresses for comfort.
• You can prevent transmission to family members by washing your hands after you touch your eyes. Do not share your wash clothes or towels, and wash them in very hot water after you use them.

3. Migraine

Symptoms:

• Sudden onset of a shimmering, horseshoe-shaped, jagged light, which resembles TV static, or moonlight on water.
• There is usually a blank area in the middle of this light.
• This light starts small, grows, and then fades away, over 15-30 minutes. It may move from top to bottom, or left to right.
• A throbbing headache may occur, and last for 2-3 hours afterwards.
• You may experience some nausea.
• Migraines are common. 1 in 10 people experience migraine at some point in their lives. Thomas Jefferson, Emily Dickenson, Elvis Presley, Charles Darwin, Julius Caesar and Sigmund Freud suffered from migraines.
• Migraines are hereditary, so it is likely that you will know a family member who has migraines.

Treatment:

• ERGOTAMINE (Cafergot, Ergomar), for acute attacks.
• To prevent recurrent attacks, the beta blocker Propranolol (Inderal) can be helpful, but you should not take it if you have a history of asthma.

4. Allergic conjunctivitis

Symptoms:

• Both eyes are red, scratchy, and extremely itchy.
• This same problem tends to occur during this same month in spring or fall every year.
• Stuffy nose and a cough.

Treatment:

• Anti-histamines by mouth will be helpful if you are sneezing and coughing.
• Effective eye drops to treat allergy include Patanol, Optivar, and Cromolyn.
• Cold compresses are also helpful.
• In severe cases, you can use steroid drops such as Alrex, for short periods only.

5. Blepharitis

Symptoms:

• Edges of lids are always red.
• Continual loss of eyelashes.
• Recurrent, frequent styes.
• Eyes feel irritated.
• Mild crustiness.

Cause:

• Flakes of skin have developed along the margins of your eye lids. These flakes are the eye equivalent of dandruff on your scalp. Both are caused by excessive production of normal tissue.
• These flakes of skin eventually become infected.
• You develop styes, because the openings of the tiny glands along your lid margins become blocked by inflammation and infection.

Treatment:

• Scrub your closed lids 30 times every night with a pad such as Ocusoft or Lid Scrub.
• Warm compresses.
• Antibiotic ointment may be used along lid margins for short periods.

6. Dry Eye Syndrome

Symptoms:

• Eyes chronically burning, sandy, slightly painful, dry and somewhat red.
• Condition gets worse in the summer, when you are in air conditioning; in the winter; at high altitudes; and after long trips on airplanes.
• More common in women, in the elderly, and in patients with autoimmune diseases, such as Sjogren’s syndrome;and scleroderma.
• Can be caused by medications, especially beta blockers and antihistamines.

Treatment:

• Artificial tears, such as Refresh, Tears Naturalle, or Hypotears, 2 to 3 times a day on a regular schedule, indefinitely.
• If your symptoms do not improve, switch to preservative free tears, such as Hypotears PF. Use them 5-6 times a day. Add a small amount of lubricating ointment at night. Humidify room air.
• If severe: consider punctual plugs and moist chamber glasses.

7. Episcleritis

Symptoms:

• Episcleritis is a mild inflammation of the surface of your sclera.
• Some people have only one attack; others have many attacks, in that eye and/or the other
• One side of one of your eyes is reddish in color.
• That area is slightly tender to touch.
• The eye feels irritated.
• Your vision is unchanged.
• The cause is usually unknown. It can-RARELY-be associated with inflammatory diseases such as Lyme disease and syphilis.

Treatment:

• Non-steroidal drops, if mild.
• Steroidal drops, if severe

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NOT URGENT. No need to see an ophthalmologist unless you want reassurance

1. Sub-conjunctival hemorrhage

Symptoms:

• One side of one of your eyes has become bright red.
• The eye is comfortable.
• Your vision has not changed.
• The redness is blood that has oozed out of one of the hair-thin blood vessels in your conjunctiva. Maybe you rubbed the eye too forcefully, or blew your nose too hard.

Treatment:

• No treatment is needed. The blood will disappear on its own within several days.
• Virtually everybody gets these.

2. Stye (chalazion)

Symptoms:

• Tender lump on one of your eye lids.
• That lid is swollen and red.

Treatment:

• Warm compresses for 10-15 minutes, 3 or 4 times a day.
• You do not have an infection. You do not need to take antibiotic drops or pills.
• If this lump persists for more than a month, you may want to have it incised and drained by your ophthalmologist.
• See your ophthalmologist to find out whether or not you have blepharitis.