Rosen & Barkin's 5-Minute Emergency Medicine Consult (772 page)

• Ruptured globe
  
• Hyphema (depending on severity)
  
• Orbital cellulitis/abscess
  
• Cavernous sinus thrombosis
  
• Significant cardiac, carotid, or neurologic disease
  
• Unexplained, progressive vision loss
  

If the diagnosis is certain and visual loss will not progress

• Follow-up should be discussed with ophthalmology for emergent or urgent issues
  
• Referral for cardiac and carotid workup in embolic disease
  

• Document visual acuity for all eye complaints
  
• Topical anesthesia will aid in diagnosis as well as facilitating a proper eye exam
  
• Consider ocular issues and a detailed eye exam with headache complaints
  

• Khare GD, Symons RC, Do DV. Common ophthalmic emergencies.
  Int J Clin Pract
  . 2008;62:1776–1784.
  
• Kunimoto DY, Kanitkar KD, Makar MS.
  The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease.
  4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. Website:
  www.eyeatlas.com
  
• Mahmood AR, Narang AT. Diagnosis and management of the acute red eye.
  Emerg Med Clin North Am
  . 2008;26:35–55.
  
• Vortmann M, Schneider JI. Acute monocular visual loss.
  Emerg Med Clin North Am
  . 2008;26:73–96.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Chalazion
  
• Conjunctivitis
  
• Corneal Abrasion
  
• Corneal Burn
  
• Corneal Foreign Body
  
• Dacryocystitis
  
• Giant Cell Arteritis
  
• Globe Rupture
  
• Hordeolum
  
• Hyphema
  
• Iritis
  
• Red Eye
  
• Optic Artery Occlusion
  
• Optic Neuritis
  
• Orbital Cellulitis
  
• Ultraviolet Keratitis
  
• Vitreous Hemorrhage
  

CODES

• 368.8 Other specified visual disturbances
  
• 368.11 Sudden visual loss
  
• 369.9 Unspecified visual loss
  

BASICS

Vitreous hemorrhage is a secondary diagnosis; identification of a specific cause is necessary for successful treatment:

• Retinal vessel tear due to vitreous separation
  
• Sudden tearing of vessels due to trauma
  
• Spontaneous bleeding due to neovascularization (e.g., diabetics)
  

• Blunt or penetrating trauma
  
• Retinal break/tear/detachment
  
• Any proliferative retinopathy
  
• Diabetes mellitus
  
• Sickle cell disease
  
• Retinal vein occlusion
  
• Eales disease
  
• Senile macular degeneration
  
• Retinal angiomatosis
  
• Retinal telangiectasia
  
• Peripheral uveitis
  
• Subarachnoid or subdural hemorrhage:
  
  • Terson Syndrome
    
• Intraocular tumor
  

• Prematurity
  
• Congenital retinoschisis
  
• Pars planitis
  
• Child abuse:
  
  • Shaken-baby syndrome
    

DIAGNOSIS

• Sudden, painless unilateral loss or decrease in vision
  
• Appearance of dark spots (floaters), cobwebs, or haze in visual axis:
  
  • Above findings sometimes accompanied by flashing lights; floaters move with head movements
    
• Blurred vision, decreased visual acuity
  
• Loss of red reflex
  
• Inability to visualize fundus
  
• Mild afferent papillary defect
  

• Ocular or systemic diseases
  
• Trauma
  

Fundoscopic exam:

• Absent red reflex
  
• No view of the fundus
  
• Acute:
  
  • RBCs in anterior vitreous
    
• Chronic:
  
  • Yellow appearance from hemoglobin breakdown
    

• History with special attention to pre-existing systemic disease and trauma
  
• Complete ocular exam including:
  
  • Slit lamp
    
  • Tonometry
    
  • Dilated fundoscopic exam
    

• CBC
  
• PT/PTT/INR if indicated
  
• Electrolytes, BUN, creatinine, glucose
  

• B-scan US when no direct retinal view is possible to rule out retinal detachment or intraocular tumor
  
• Fluorescein angiography to define the cause
  
• CT scan/anteroposterior/lateral orbital films to rule out intraocular foreign body
  

If nontraumatic, scleral depression

• Vitreitis (leukocytes in the vitreous):
  
  • May include anterior or posterior uveitis
    
• Retinal detachment without hemorrhage
  
• Central retinal venous occlusion (CRVO)
  
• Central retinal artery occlusion (CRVA)
  

TREATMENT

Protect the eye from trauma or pressure:

• Monitor BP
  

• Bed rest with head of bed elevated
  
• No activity resembling Valsalva maneuver (lifting, stooping, or heavy exertion)
  
• Avoid NSAIDs and other anticlotting agents.
  

• Urgent ophthalmologic consultation within 24–48 hr is needed with treatment based on the cause of the hemorrhage; an exam is carried out by the consultant:
  
  • Laser photocoagulation or cryotherapy for proliferative retinal vascular diseases
    
  • Repair of retinal detachments
    
• Surgical vitrectomy is needed for:
  
  • Blood that does not clear with time
    
  • VH from retinal detachement
    
  • Associated neovascularization
    
  • Hemolytic or ghost-cell glaucoma
    

FOLLOW-UP

Retinal break or detachment

Retinal break or retinal detachment must be excluded as cause of hemorrhage.

Re-evaluation daily for 2–3 days; if etiology is still unknown, B-scan US every 1–3 wk.

• Be sure to consider alternate diagnoses of CRVO or CRAO.
  
• Consider retinal detachment.
  
• Get history of trauma and use of blood thinners.
  
• Even minor bleeds require urgent ophthalmology consultation.