Ocular Emergencies

Chapter 19 Ocular Emergencies




The conditions discussed in this chapter are the most important disorders for which early action is necessary to prevent severe or permanent damage to the eye. Emergency treatment is outlined separately for ready clinical reference, followed by further discussion for those conditions not covered elsewhere in the text.




PROPTOSIS OF THE GLOBE






Emergency treatment for proptosis of the globe (Figure 19-1)









7. Roll out the lid margins with hemostats or forceps and place a temporary tarsorrhaphy suture. In general, three or four simple interrupted or horizontal mattress sutures of 4/0 nylon are used as shown in Figure 19-2, A and B. Sutures should emerge from the lid margin (in line with the meibomian gland openings) rather than on the conjunctival surface so as to prevent sutures rubbing on the cornea.


9. Place a scalpel handle over the cornea, which is well lubricated with either an antibiotic or artificial tear ointment, and draw up on each of the sutures simultaneously, as shown in Figure 19-2, C and D. This maneuver prevents forward movement of the globe while pulling the eyelids up and over the cornea. Once the cornea is protected, tie the sutures (Figure 19-2, E). If necessary (i.e., if pressure is extensive), additional sutures may be placed between the original sutures. Usually the medial canthus is left open for a few millimeters so topical medications may be applied.





Prognosis


If there is any doubt as to whether the globe can be salvaged, an attempt should be made to replace it back into the orbit. The sooner the eye is replaced, the better the prognosis, both for saving the eye and for shortening the convalescent period. Unfortunately, some eyes are inevitably lost despite early and vigorous treatment. Enucleation as the initial therapy should be considered if (1) the owner is unwilling or unable to provide what may be potentially long-term postoperative care, (2) the eye has ruptured, (3) three or more extraocular muscles are torn, or (4) the eye is completely filled with blood. The following are useful prognostic indicators.







Maintenance Therapy






Keratoconjunctivitis sicca and corneal ulceration secondary to exposure are common in the postoperative period. Supplemental artificials tears or topical antibiotic ointments are often required for several weeks or longer after proptosis to lubricate the eye and prevent infection. Additionally, many severely traumatized eyes demonstrate a deep corneal vascularization that proceeds from the limbus to the center of the cornea before gradually regressing over 4 to 8 weeks. If the cornea is not ulcerated or subject to exposure, topical corticosteroids (0.1% dexamethasone or 1% prednisolone acetate) may be used every 6 to 12 hours in an effort to moderate this vascular response.


In some patients chronic partial exophthalmos and chronic corneal exposure continue to be problems. Usually this situation results from facial nerve palsy, damage to extraocular muscles that retain the globe in the orbit, organized blood/scar tissue within the orbit, or eyelid retraction. In affected patients further surgical intervention, such as extraocular muscle repair, permanent medial or lateral tarsorrhaphy, or, in extreme cases, enucleation, should be considered. Mild cases usually do not need surgery and may be managed with supplemental artificial tear ointment to prevent corneal drying.

Aug 11, 2016 | Posted by in INTERNAL MEDICINE | Comments Off on Ocular Emergencies
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