Ophthalmic emergencies

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1. Paediatric and adult patients
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. Keratoconus
9. Lid lacerations and infections
10. Ocular and orbital trauma
11. Optic nerve head swelling
12. Ptosis
2. Adult patients (aged 16 years or over)
1. Age-related macular degeneration
2. Cataracts
3. Diabetic retinopathy
4. Eyelid malposition (entropion and ectropion)
5. Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy
6. Glaucoma
7. Lid lesions
8. Macular hole or epiretinal membrane
9. Posterior capsular opacity
10. Pterygium
11. Strabismus or ocular motility disorder
3. Paediatric patients (aged 0 to 15 years)
1. Anisocoria (unequal pupil size)
2. Cataracts
3. Congenital glaucoma
4. Nystagmus
5. Reduced visual acuity
6. Strabismus or ocular motility disorder
7. Uveitis

Paediatric and adult patients

Absent/poor red reflex

• If absent or poor red reflex, contact on-call hospital consultant or registrar for same day 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).
• 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).

Keratoconus

• Keratoconus with acute graft rejection.
• Keratoconus with acute hydrops.

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

• Ptosis with anisocoria.
• Ptosis with other neurological signs.
• Sudden onset ptosis with or without diplopia.
• Sudden onset ptosis with or without strabismus.

Adult patients (aged 16 years or over)

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.

Eyelid malposition (entropion and ectropion)

Entropion or ectropion with acute ocular pain and redness (i.e. at risk of microbial keratitis).

Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy

Acute onset and debilitating painful eye with Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy.

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.

Lid lesions

Periorbital skin cancer causing eyelid malposition with acute ocular pain and redness (i.e. at risk of microbial keratitis).

Macular hole or epiretinal membrane

Nil emergency criteria.

Posterior capsular opacity

Nil emergency criteria.

Pterygium

Nil emergency criteria.

Strabismus or ocular motility disorder

• Blow-out fracture.
• Sudden onset of limitation or reduction in ocular motility.
• Sudden onset binocular diplopia.
• Sudden onset strabismus.

Paediatric patients (aged 0 to 15 years)

Anisocoria (unequal pupil size)

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

Cataracts

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

Congenital glaucoma

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

Nystagmus

Aged > 6 months with any new, sudden onset nystagmus.

Any nystagmus with other neurological symptoms (for example, ataxia) should be considered an emergency irrespective of child’s age.

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.

Uveitis

New onset uveitis.