- Chemical injury
- Conjunctivitis (Viral, bacterial, allergic)
- Full thickness/ Penetrating Corneoscleral trauma
- Infectious keratitis (Corneal ulcer, herpes simplex/zoster keratitis)
1. Chemical injury
This should be treated within 10 mins of presentation. Acidic agents tend to coagulate and do not penetrate deep into the surface layers of the eye unlike alkali agents which do and erode deeper with time.
Check the PH of the eyes using a PH indicator paper dipped in the lower fornix.
Instill a drop of local anaesthetic (e.g Proxymetacaine 0.5%) into to both eyes.
Commence irrigation with two liter of fluid (e.g NaCl 0.9% or Hartmann’s solution) set up on a drip stand, run through a giving set held over the eye. The patient may want to lie down on an absorbent pad with a bucket or vomit bowel on the floor to catch the superfluous fluid. A Morgan lens may be used (if so follow manufacturing usage guidelines).
Evert the lids and clear the eye of any foreign bodies by gently sweeping the fornices with a moistened cotton bud.
Check the PH five minutes after every litre of fluid instilled and continue to irrigate until the PH is between 6.5 and 7.5.
Check the patient’s pain level. A drop of local anaesthetic (e.g Proxymetacaine 0.5%) may be instilled every 10 minutes.
If the lips, mouth, face or airways are involved discuss with ENT/ burns.
The patient will need to be discussed with an ophthalmology doctor.
Please refer the patient to the Eye emergency Clinic as soon as the emergency first aid treatment has been performed.
Viral conjunctivitis: Treatment is supportive. Advise regular analgesia such as paracetamol, cool compresses and ocular lubricating drops. It may take several weeks to resolve. It is highly contagious and patients should be advised to employ strict hand hygiene, not to share towels or bedding with others, and to take time off work or school until resolution.
Bacterial conjunctivitis: With mucopurulent (pus) discharge, take a swab for culture and sensitivity and send to the lab. Treat with topical antibiotics such as g. chloramphenicol 0.5% four times a day for a week.
Always consider gonorrhea or chlamydial infection (ophthalmia neonatorum) in a baby presenting within a month of life. Swabs should be taken and the baby referred to paediatrics and ophthalmology for further assessment.
3. Full thickness/ Penetrating Corneo-scleral trauma
CT head and orbit is indicated to assess for orbital wall fracture, head injury or intraorbital foreign body.
Use a cartella shield over the affected eye and refer to the Emergency eye unit at queens Hospital immediately.
Call the ophthalmology urgent advice line: 01708435000 Ext. 6662. (Or Moorfields Eye Hospital out of hours).
Refer to main Emergency Department if there are other injuries.
Start the patient on Coamoxiclav (or Erythromycin if penicillin allergic) and check up-to-date tetanus prophylaxis.
4. Infectious keratitis (Corneal ulcer, herpes simplex/zoster keratitis)
Patients present with foreign body sensation, watering and photophobia, frequently with a history of contact lens use. Corneal ulcers require urgent attention.
The pathogens in contact lens wearers tend to be more aggressive and the patient needs a referral to ophthalmology for further assessment.
If out of hours please start the patient on g. Chloramphenicol 0.5% QDS or g. 5mg/ml Levofloxacin hourly day and night if they are a contact lens wearer. Advise them NOT to wear their contact lenses. Please fill in the urgent eye care referral form [docx] 17KB and email it to email@example.com. We will see them the next day in the Emergency Eye clinic.
Herpes simplex keratitis
Often recurrent in a patient with a history of herpes simplex infection elsewhere e.g cold sores/ genital ulcers. The eye is often red and irritated and there may be a dendritic shaped lesion that stains after instillation of fluorescein seen under blue light.
Please start g. Chloramphenicol 0.5% QDS and Ganciclovir 0.15% 5 x a day for 7/7. Please fill in the urgent eye care referral form [docx] 17KB and email it to firstname.lastname@example.org. We will see them the next day in the Emergency Eye clinic.
Herpes zoster ophthalmicus
Corneal infection with Varicella Zoster virus. It tends to occur in elderly or immune-compromised patients. Patient presents with tingling and shooting pain in the area of the ophthalmic nerve (trigeminal) and may have a cluster of vesicular lesions which may burst and scab over. The eye may or may not be affected.
Please refer to local VZV guidelines: start on Po Acyclovir 800mg 5 x day and lubricating eye drops. Please fill in the urgent eye care referral form [docx] 17KB and email it to email@example.com. We will see them the next day in the Emergency Eye clinic.