Ophthalmic emergencies

On this page

1. Paediatric and adult conditions
   
1. Absent/poor red reflex
2. Acute neuro-ophthalmic signs or symptoms
3. Acute red eye
4. Acute visual disturbance
5. Blow-out fracture
6. Chemical burns
7. Corneal foreign body
8. Lid lacerations and infections
9. Ocular and orbital trauma
10. Optic nerve head swelling
11. Ptosis
2. Adult conditions
1. Age-related macular degeneration
2. Cataracts
3. Diabetic retinopathy
4. Glaucoma
3. Paediatric conditions
1. Anisocoria (unequal pupil size)
2. Cataracts
3. Congenital glaucoma
4. Reduced visual acuity
5. Strabismus or ocular motility disorder

Paediatric and adult conditions

Absent/poor red reflex

• If absent/poor red reflex, contact on-call hospital consultant/registrar same day for advice.
• White pupil in one or both eyes (paediatric only).

Acute neuro-ophthalmic signs or symptoms

• Acute onset anisocoria (unequal pupil size) with or without neurological signs.
• Sudden onset strabismus (ocular misalignment).
• Acute ptosis.
• Acute onset nystagmus.

Acute red eye

• Abnormal cornea, indicating Herpes simplex infection, bacterial or acanthamoebal ulcer, marginal keratitis or foreign body / corneal abrasion.
• Photophobia and marked decrease in visual acuity.
• Conjunctivitis with reduced vision or not responding to treatment.
• Red eye in the context of corneal transplant or contact lens wear.
• Acute angle closure crisis.
• Acute painful eye with sudden loss of vision.
• Scleritis.
• Acute anterior uveitis (iritis).
• Hypopyon.
• Hyphaema.
• Flash burn.

Acute visual disturbance

• Sudden, persistent loss of vision.
• Painless loss of vision over hours to days.
• Reduced visual acuity, colour vision, brightness and contrast vision.
• Swollen optic disc.
• Acute onset monocular visual loss.
• Transient visual loss.
• Orbital pain, with or without eye movement.
• Recent history of increased number of visual floaters and/or flashes.
• Dark shadow in the vision of the affected eye.
• Fundus examination shows large areas of haemorrhage and/or emboli.

Blow-out fracture

• Pain on eye movements.
• Nausea or vomiting on eye movements.
• Minimal redness and swelling (white-eye blow-out fracture in a child).
• Local tenderness.
• Diplopia.
• Eyelid swelling.
• Crepitus after nose blowing.
• Findings suggestive of minimal periorbital haemorrhage, sunken (enophthalmic) globe and restricted eye movement in an unwell child.
• Nose bleed.
• Ptosis.
• Localised tenderness.
• Suspected or documented orbital floor fractures.
• Evidence of ocular injury.

Chemical burns

Acid or alkali in contact with eye.

Corneal foreign body

• Any foreign body penetration of the cornea or retained foreign body.
• Foreign body is not completely removed.
• Underlying surface defect is opaque and indicative of an abscess.
• Persistent epithelial defect (i.e. significant or minimal improvement within 48 hours).

Lid lacerations and infections

• Eyelid laceration is associated with ocular trauma requiring surgery (e.g. ruptured globe, intraorbital foreign body).
• Laceration position is nasal to either the upper or lower eyelid punctum.
• Extensive tissue loss or distortion of the anatomy.
• Full thickness laceration.
• Laceration involves the lid margin.
• Suspected pre-septal or orbital cellulitis.

Ocular and orbital trauma

• All penetrating trauma.
• Reduced ocular movements.
• Findings are suggestive of intraocular haemorrhage, ruptured globe or orbital wall fracture.

Optic nerve head swelling

• Optic nerve head swelling with neurological signs or symptoms, vision change and/or headache.
• Optic nerve head swelling with retinal haemorrhages or exudates.

Ptosis

• Sudden onset ptosis with or without diplopia.
• Ptosis with other neurological signs.
• Ptosis with anisocoria (unequal pupil size).

Adult conditions

Age-related macular degeneration

• Sudden loss of vision.
• New onset of reduced central vision and/or distortion due to wet age-related macular degeneration (AMD).
• New fluid on a macular optical coherence tomography (OCT) scan consistent with wet AMD.

Cataracts

• Recent cataract surgery with increasing pain, redness, blurring or flashes/floaters.
• Acute angle closure.

Diabetic retinopathy

• Sudden loss of vision.
• Proliferative Diabetic Retinopathy (PDR).
• Vitreous haemorrhage.
• Severe non-proliferative diabetic retinopathy (NPDR) in pregnancy.
• Centre-involving macular oedema in pregnancy.
• Retinal detachment.

Glaucoma

• Acute angle closure crisis.
• Acute painful eye with sudden loss of vision.
• Intraocular pressure (IOP) > 35 mmHg.
• Red and painful eye with history of glaucoma drainage surgery.

Paediatric conditions

Anisocoria (unequal pupil size)

Acute onset anisocoria (unequal pupil size) with or without neurological signs.

Cataracts

• New cataract for aged < 3 years.
• Cataract with red eye.
• Cataract with nystagmus.
• Cataract with congenital glaucoma.

Congenital glaucoma

• Big eye(s) (horizontal corneal diameter > 12mm).
• Cloudy cornea.
• Photosensitivity with tearing.

Reduced visual acuity

Sudden and/or severe vision loss in a child.

Strabismus or ocular motility disorder

• Sudden onset strabismus (squint) with diplopia.
• Suspicion of nerve palsy with other cranial nerve and/or neurological signs.
• Abnormal red reflex or lack of visual response.