Acute Angle-Closure Glaucoma (AACG)
Overview
An acutely painful eye with systemic upset (particularly nausea and/or vomiting) should raise suspicion of acute angle-closure glaucoma (AACG). Other features include:
- Headaches
- Abdominal pain
- Halos around lights
- Semi-dilated non-reacting pupil
Initial steps
- Refer immediately to ophthalmology
- If immediate admission is not possible, give pilocarpine and acetazolamide eyedrops and lie the person flat with the head not supported by pillows
- Emergency medical treatment may involve:
- A combination of eyedrops (beta-blockers, parasympathomimetics, beta-blockers, alpha-2 agonists)
- IV acetazolamide
- Definitive management involves laser peripheral iridotomy
Giant Cell Arteritis (GCA)
Overview
Visual loss without eye pain in a patient >50 should raise suspicion of giant cell arteritis (GCA, temporal arteritis). Associated features include:
- A history of polymyalgia rheumatica – prolonged morning stiffness that worsens with rest and improves throughout the day, weight loss, and fever
- Scalp tenderness
- Jaw claudication
Initial steps
- Immediately start high-dose corticosteroids:
- If no visual involvement: oral prednisolone
- If visual involvement is present: IV methylprednisolone
- Perform FBC, ESR, and CRP testing
- A temporal artery biopsy may need arranging
- Immediately refer to rheumatology if no visual involvement/ophthalmology if visual involvement present
Orbital Cellulitis
Overview
Fever, headaches, proptosis, and limited eye movements suggest orbital cellulitis. The ocular pain is severe and there is often associated swelling around the eye. Proptosis and pain with eye movement are not associated with preseptal cellulitis.
Initial steps
- Immediately admit to hospital for IV antibiotics
- Full blood count:
- May show leukocytosis
- CRP:
- May be raised
- CT with contrast:
- Confirms diagnosis
- Blood culture:
- Ideally should be done before giving IV antibiotics but do not delay treatment
Postoperative Endophthalmitis
Overview
A painful red eye with acute vision loss following surgery suggests postoperative endophthalmitis, which describes an infection of the posterior and anterior segments of the eye. It is severe and sight-threatening.
Initial steps
- Immediately refer to ophthalmology
Posterior Vitreous Detachment and Retinal Detachment
Overview
Flashes, floaters, circles, and cobwebs should raise suspicion of posterior vitreous detachment, which is where the vitreous humour shrinks and pulls away from the retina. Eventually, the retina can tear and allow vitreous humour to seep through, leading to retinal detachment and vision loss described as a ‘curtain coming down’ over hours to days.
Initial steps
- All new flashes and floaters warrant an immediate referral to ophthalmology
CN III (Oculomotor) Nerve Palsies
Overview
CN III palsies can occur due to ‘medical’ causes such as diabetes mellitus and hypertension, or ‘surgical’ causes such as tumours or aneurysms. All CN III palsies are urgent, regardless of pupil involvement, as it is difficult to rely on a clinical examination alone to rule out ‘surgical’ causes.
Features include:
- Diplopia
- The eye is deviated ‘down and outwards’
- Ptosis
- Dilated pupil – suggests a ‘surgical’ cause
- An associated headache suggests a posterior communicating artery aneurysm
Initial steps
- Immediately refer to neurology
- Investigations may include:
- CT brain – to screen for a mass lesion
- MRI brain – to screen for a mass lesion
Eye Trauma
Overview
Eye trauma following reduced vision requires an urgent ophthalmologic assessment. This is due to the risk of blood accumulating in the eye, increasing the intraocular pressure (IOP) which can threaten vision.
Neonatal Conjunctivitis
Overview
Sticky eyes and conjunctivitis in a neonate may suggest Chlamydia or Neisseria gonorrhoea infection, which can be sight-threatening. Purulent discharge in the first week of life is an infection with Neisseria gonorrhoea until proven otherwise. An immediate referral to an ophthalmologist or paediatrician is indicated.
Leukocoria (White Pupil)
Overview
A white pupil may suggest retinoblastoma, which is a life-threatening tumour. This may replace the red reflex. An urgent referral to ophthalmology should be made if leukocoria is seen.
