Ocular First Aid Kit Essentials

Ocular First Aid Kit

• Necessary medications for an ocular first aid kit:
  • 1% amethocaine: A local anesthetic used to numb the eye for procedures
  • 1% atropine: Dilates the pupil and temporarily paralyzes the ciliary muscle
  • 2% pilocarpine: Constricts the pupil, used in some glaucoma treatments
  • 1% chloramphenicol (ointment): A broad-spectrum antibiotic used to treat bacterial eye infections
  • 0.3% ofloxacin: Another antibiotic eye drop for bacterial infections
  • 1% prednisolone acetate: A corticosteroid to reduce inflammation
  • 0.5% timolol: Beta-blocker eye drops to lower intraocular pressure
  • 0.5% apraclonidine: Alpha-adrenergic agonist to lower intraocular pressure
  • 2.0% dorzolamide: Carbonic anhydrase inhibitor that reduces fluid production in the eye
• Instruments and consumables needed:
  • Sterile gauze pads: For cleaning and protecting the eye
  • 3cm transpore surgical tape: For securing dressings or shields
  • Fox shield: Used to protect the eye after injury or surgery
  • Litmus paper: To test the pH of the eye in chemical injuries
  • 0.9% saline irrigation (2-4 litres) & drip kit: For irrigating the eye, especially after chemical exposure
  • Clean towels for irrigation: To keep the area clean during irrigation
  • Jewellers forceps: For removing foreign bodies
  • 25G needles: For specific procedures that require a needle
  • FB spud: An instrument for removing foreign bodies
  • Speculum/lid retractor: To hold the eyelids open for examination or procedures
  • Bandage CLs (SiHy): Silicone hydrogel contact lenses used as a bandage for corneal injuries

Ocular Emergencies - Overall Plan

• Measure visual acuity (VA) first whenever possible, except when a chemical burn is suspected
• Decide very quickly whether to manage the patient or refer
  • Time is critical, and delay can lead to serious consequences
• Seek advice or refer if unsure
• Arrange appropriate transport to the referral center
  • An ambulance is a good choice for severe cases

Extrinsic Causes of Red Eye

• Subconjunctival Hemorrhage: Bleeding between the conjunctiva and sclera
  • Causes include Valsalva maneuvers, trauma, hypertension, diabetes, or bleeding disorders
  • Ask about recurrence
  • Anticoagulant or antiplatelet medications, do not stop anticoagulant medication
  • May be related to topical steroid use or a rare orbital mass; can also be idiopathic
  • For bilateral cases, consider systemic investigation
  • Document the edges of the hemorrhage, either by measuring or photographing
  • Typically resolves in 2-3 weeks
• Conjunctivitis
  • Bacterial: Treat with antibiotics
    • Decide if treatment is necessary
    • Severity, discomfort (many resolve within 5 days without treatment)
    • Corneal involvement: SPK, marginal infiltrate, ulcer
    • If treating with an antibiotic
      • CL wear: no chloramphenicol; ensure coverage for gram negative eg fluoroquinolone or tobramycin
      • Lid involvement: Decide if it is the primary site of infection, consider if ointment is indicated
      • Minimum qid
      • Continue dose for 5 to 7 days
      • review 24-48 hours - If improving, continue treatment - If not improving within 48 hours for a moderate conjunctivitis, then reconsider the diagnosis but remember sometimes there may be a lag in resolution - When cornea is clear, continue to treat for another 48 hours
  • Viral: Treatment may be limited for corneal involvement
    • If adenovirus
      • Ocular lubricants
      • Providone-iodine 1.25% rinse: has been proposed; not evidence-based
        • will need a steroid too as iodine causes ocular surface irritation
    • If evidence of HSV keratitis – dendritic ulcer
      • Immediate acyclovir 3% ointment -1cm ointment into the lower fornix 5x/day for 14 days or for 3 days after epithelial defect has completely resolved -Listed as restricted on PBS: only for HSV keratitis
      • Review 24 hours and 48 hours
        • If resolving, then review every 2 days
        • If not resolving, refer
  • Allergic: Treatment depends on severity; follow a stepped approach
    • Non-pharmaceutical measures include allergen avoidance and cold compresses
    • Ocular lubricants used, possibly with saline irrigation
    • Vasoconstrictors used
    • Antihistamines: Levocabastine 0.5% (SAC)
    • Antihistamines and vasoconstrictors: Naphcon A (Alcon) 0.025% naphazonline HCl and 0.3% pheniramine maleate
    • Oral antihistamines
    • Mast cell stabilizers: Sodium cromoglycate (delayed reaction ~ 10 days), lodoxamide
      • bid, review 24 hours, then weekly until resolved or allergen (if identified) is removed)
    • Antihistamines and mast cell stabilisers: Ketotifen 0.025% and olopatadine 0.1%
    • NSAIDs
    • Steroids: fluorometholone
    • Watch IOPs if using steroids

Unilateral Red Eye with Decreased Vision

• Corneal ulcer +/- NaFl staining: Infection or sterile; dendritic ulcer, antibiotics, steroids, refer?
• High IOP, closed angles: AAC 2° to uveitis?, Lower IOP. Refer
• Cells in AC: Scleritis, episcleritis, posterior uveitis, Correlate redness with cells. Anti-inflammatories. Refer?
• Normal vitreous & retina: Posterior uveitis, endophthalmitis, Refer
• Acute anterior uveitis?: AC cells& flare, synechia, photophobia, epiphora, pain, Steroids. Refer?

Bilateral Red Eyes with Normal Vision

• Mucopurulent discharge: Bacterial conjunctivitis, Antibiotics
• Watery discharge, follicles +/- flu: Viral conjunctivitis, Symptomatic relief unless HSV (rare bilateral)
• ITCH. watery discharge: Allergic conjunctivitis, Lubricants, antihistamines, MCS, steroids
• No discharge +/- itch, gritty: Blepharitis, dry eye, Warm comp, lid hygiene, lubricants, antibiotics
• Chronic: >4/52 +/- follicles: Chlamydia, Refer

Unilateral Red Eye with Normal Vision

• Marked Pain, photophobia, haloes: Early: AAU or keratitis, Steroids, or antiviral or antibiotic
• Absent or mild Pain, photophobia, haloes: Watery discharge, lid follicles; pre-auricular node swelling or recent URTI, Viral conjunctivitis, Lubricants, povidone iodine
• Absent or mild Pain, photophobia, haloes: Watery discharge, lid follicles; pre-auricular node swelling or recent URTI, Subconjunctival haem, episcleritis, RCE, chronic conjunctivitis, Lubricants, NSAIDs, steroids

Extrinsic Ocular Trauma

• Chemical: Acid, Alkali, Organic solvents
• Abrasions: Epithelium
• Lacerations: Stroma
• Thermal or Radiation Burns
• Blunt Trauma: The iris may be involved

Chemical Trauma

• Patients report a chemical splash in the eye; the specific chemical is often known
• Determine whether the chemical is acidic or alkaline
• Patients will have a painful red eye and reduced visual acuity
• Eye burns without pain indicate possible nerve destruction

Chemical Trauma Grading

• Dua, King and Joseph Grading System - Grade I: Large corneal burn from ammonia. No limbal or conjunctival involvement - Grade III(5/35%): Ocular surface burn from industrial alkaline chemical - Grade IV (7/50%): Ocular surface burn from an acid burn & one year after a full thickness corneal transplant - Grade V (9.5/60%): Ocular surface burn from alkali injury & 13 months after ocular surface reconstruction - Grade VI (12/100%): Ocular surface burn following injury with cement powder (7 months after the injury)
• Roper-Hall Classification
  • Grade I: Corneal epithelial damage, no limbal ischemia, good prognosis
  • Grade II: Corneal haze with iris details visible, <1/3 limbal ischemia, good prognosis
  • Grade III: Total epithelial loss, stromal haze obscuring iris details, 1/3-1/2 limbal ischemia, guarded prognosis
  • Grade IV: Opaque cornea obscuring iris and pupil, >1/2 limbal ischemia, poor prognosis

Chemical Trauma: Acids

• Causes coagulation of proteins in the anterior segment and in the lids, corneal epithelium/stroma coagulated proteins form a barrier to further; usually anterior chamber is not affected
• Common Agents Include
  • Sulphuric acid from batteries
  • Hydrochloric acid from pool chemicals: Grade I chemical injury from hydrochloric acid that only resulted in corneal involement. Coagulated corneal epithelium resulted in "ground glass" appearance
  • Hydrofluoric acid from glass etching & cleaning

Chemical Trauma: Alkalis

• True ocular emergency
• Saponifies fatty acids of cell membranes, destroys collagen and penetrates though the eye if not stopped
• Alkali agents will affect the lids, conjunctiva, cornea- including corneal stem cells and the anterior chamber
• Common agents include ammonia, sodium hydroxide from cleaning fluids, and calcium hydroxide from lime and cement

Chemical Trauma: Organics

• Common agents include petrol and other solvents
• These are highly lipophilic substances that melt cell membrane collagen
• Unlike alkalis, they are quite volatile and are likely to evaporate from the ocular surface

Chemical Trauma: Unknown Chemicals

• Assume the worst and treat accordingly as soon as possible

Chemical Trauma: Initial Treatment and Triage

• Flush eye immediately with sterile saline or tap water if no saline available
  • For at least 30 minutes; ignore the discomfort, wet clothes, repeat eye wash!
  • Continue until litmus paper indicates that pH has returned to 7
• Take patient history while irrigating
• Refer cases worse than grade I
• If worse than grade III, call ambulance, then keep irrigating

Chemical Trauma: Assessment and Treatment

• More likely to manage grade I acid/organic solvent injuries (possibly grade II)
• After irrigating for at least 30 minutes and establishing neutral pH
  • Instil local anaesthetic: Amethocaine 1% - Use NaFl to visualize epithelial defect for grading. - Lid eversion to check for any remaining matter. - Prophylaxis given to patient; and treatment options
    • Antibiotic drops(tobramycin/fluoroquinolone), cycloplegia (atropine qd), bandage CL if mild/moderate, topical steroid if an anterior chamber flare is present (Flarex qid)
    • If IOP can be measured, check that it is not elevated!

Abrasion

• Typically from fingernails, gardening injuries etc.
• Patients can usually tell what happened.
• Symptoms include: Painful, watery, red eye, +/- photophobia
• Assessment: Measure vision/VA

Abrasions: Examination

• Conduct Careful anterior eye examination
  • Local anaesthetic may be needed
  • Assess for FB presence
  • Check for eyelid eversion
  • Assess and measure epithelial defect
  • Check for stromal involvement

Treatments of Abrasions Include

• Debridement of loose epithelium
• Ocular lubricants
• Prophylactic antibiotic qid (eg chloramphenicol) for 3 days after epithelial defect has healed
• Bandage CL if required Don't patch! Rev 24 hours - if RCE, night-time lubricant ointment

Lacerations

• Patients will present with a very open eye that can be telling of ocular injury
• Often have have painful, watery, red eye, +/- photophobia
• Manage, triage or refer after a quick immediate assessment
• Discomfort should ease very quickly w/ local aesthetic during examination
• Examine the laceration injury closely with
  • Careful anterior eye examination assess for FB presence/material and lid eversion

Examine conjucntiva; instil NaFl & check for injuries + any perforations, and differentiate diagnoses from corneal ulcers.

Management of Lacerations Include

• Clear or remove any FB material
• Prophylactic antibiotic for 3 days after epithelium heals, eg chloramphenicol qid
• Ocular lubricants should be frequently used
• Steroids and cycloplegics for comfort, use SiHy bandages, and review every 24 hours

Trauma: Foreign Bodies

• Anytime there is trauma, always rule out foreign bodies
• The most common foreign bodies are from fast moving objects/accidents like power tools, airborne particles, explosions
• Carefully assess those with vitreous inflammation using seidel test

Examination; Foreign Bodies

• Those that present with painful, red, sore, eye (worse with bright light) will provide history
• Manage or refer immediately
  • History should include: history of the injury and any foreign bodies + measure of visual activity
  • if metallic is suspected, check for rust ring and always asses for perforation using topical dye

Management of Foreign Bodies Include

• Remove any FB materials, and/or rust rings
• Give plenty of Ocular lubricants prescribed prophylactic antibiotics + A bandage if necessary

Trauma: Radiation and Thermal Burns

• Radiant heat and UV light can cause burns to the ocular structures, such as “welder’s flash” and “snow blindness.”
• Triaging steps
• Pain experienced by patient, redness, sensitivity to UV light/brightness
• Perform Examination
  • Full history should be taken of patient including visual acuity- while using local anesthetic
  • Take a good look at front and back eye after applying dye(NaFl) Manage or refer immediately if needed through management
• Use ointment and lots of irrigations to remove any extra epithelium
• Bandage to keep moisture in using a wet qid if needed + Cycloplegia; expect improvement soon

Blunt Trauma

• The patient presents with a history of blow to the face
• Symptoms experienced are often variable- including; diplopia, reduced VA, pain and redness haemorrhage

Examination for Blunt Trauma

• Manage or refer- start examination quickly with full history of injury and visual acuity test
• Watch for a lot of irritation due to light on eye as it can be a cause of the pain
• Watch out for globe rupture if applicable using seidel
• Rule out orbital blow fractures

Treatment for Blunt Trauma

• Use lots of steroids, as well as other types of drugs

Blunt Trauma - Iris Damage

• Hyphema - Source of bleeding is typically the iris root or ciliary body face. Blood can appear in various forms with little or significant damage.
• Vassius ring
  • This means compression of pupil; resulting in pigment marks left on lens. - There will be extra pupil damage; causing vision blur.
• Trauma:* This damage will often cause pupil dilation/contraction tears called Iridodialysis

What do you examine when dealing with Blunt trauma and pupil damage?

Test pupil for reaction and check retina and assess degree of bleeding- this will determine referral level

• Important* Do Not Touch pupil if vessel tears; risk for high pressure!
  • Always keep above eye elevated and use steroids and Beta blocker if IOP is too high

Emergency Presentations

• Sudden loss of vision
• If not red and not painful:
  • First exclude posterior uveitis
  • Can be from more serious conditions, that can encompasses retinal, optic nerve and CNS.

Retinal Detachment - Emergency

• Sudden loss of vision
  • May also be described progressively; more like a curtain blocking
  • Floaters and sensitivity to UV rays is an early sign
    • Check for Pigment in anterior vitreous; Shafer’s sign - this can be an indicate sign of tear
• Examination and Diagnoses* Determine amount of pupil with tests and check/assess for those injuries

Central Retinal Artery Occlusion (CRAO)

• Sudden painless loss of vision (unless other supplies are damaged that cause pressure and pain

Often this is associated with heart conditions or other older age problems

• Full history should also have all heart related history!

To Determine; Examine for Emboli (Hollenhorst plaques) Often this leads to Arterial necrosis and further damage - requiring urgent referral Attempt dislodgement of extra clots and check pupils, but can damage as is difficult to manage and help at the same time

Giant Cell Arteritis

• A true ocular emergency

• Inflammation of the medial wall of muscular arteries

• Watch for; throbbing headache, jaw pain, scalp tenderness + sensitivity of temporal artery

  • decreased VA
  • Pale Swollen- haemorrhages around or any cornea problems due to decreased circulation
  • Involve those with a stroke history and/or at immediate risks as stroke damage is very high
  • Examination; Test pupils and visual check immediately

Transient Ischemic Attack

• A quick, temporary and sudden loss of vision
  • Examine those with stroke risks, as well as potential arterial problems
• Those at high risk are those with Hollenhorst plaques (arterial clots); those with any blood damage is extremely important.
• Always consult, monitor and assess, and check the symptoms align with migraine, but if unsure, test pupils and retina and recommend to GP immediately.

Orbital Cellulitis

Very serious and dangerous to child/person

• Starts like general infections around facial bone
• Will have inflammation pain around movements
• Proptosis can quickly develop; consult team if they are at more and more risk Test Pupils+ do eye scans
• Act at emergency attention; and treat the potential risk of blindness and bacterial meningitis

Endophtalmitis

• Emergency with sudden onset

Ambulance needs to be set up so that it can be transferred asap (Can cause Vitreous Issues, inflammation and high pressure)

Acute Angle Closure (AAC)

Patients will have; severe red eye, cornea issues, fixed pupil

• often complain with a headache and nausea - (often occurs more later on ) To Determine damage: Always give eye examinations if possible.

Often ask to lower/increase pressure using beta blockers, recommend the patients to GP to test the pupils, as soon as comfortable