GCC Nursing: Ophthalmic Emergencies & Eye Care

TRIAGE PRINCIPLE

Ophthalmic emergencies can cause permanent vision loss within minutes. Rapid nursing assessment and escalation is critical. When in doubt — escalate immediately.

Eye Emergency Categories

⚠

Immediate (Sight-threatening — Act Now)

Chemical Eye Burns — irrigate BEFORE full assessment, every second counts
Acute Angle Closure Glaucoma (AAOG) — IOP >50 mmHg, severe pain, fixed dilated pupil
Central Retinal Artery Occlusion (CRAO) — painless sudden vision loss, 3-hour window
Orbital Cellulitis — proptosis, restricted eye movement, fever — IV antibiotics urgently

Immediate Action Signs

pH <6 or >9 in eye
Fixed mid-dilated pupil + rock-hard eye
Sudden painless complete visual loss
Proptosis + restricted motility + fever
Penetrating/perforating eye injury

▲

Urgent (Within 1–4 hours)

Corneal Ulcer — white opacity on cornea, severe pain, photophobia, risk of perforation
Acute Uveitis (Iritis) — photophobia, ciliary flush, small irregular pupil, keratic precipitates
Hyphema — blood in anterior chamber, usually post-trauma, risk of rebleed and raised IOP
Retinal Detachment Warning Signs — new floaters + flashing lights + curtain/shadow across vision
Endophthalmitis — post-operative pain and visual loss — ophthalmic emergency within hours

●

Semi-Urgent (Within 12–24 hours)

Corneal Foreign Body — FB sensation, pain, tearing — remove within 24 hours to prevent ulcer
Large Subconjunctival Haemorrhage — post-trauma SCH or spontaneous involving full conjunctiva
Stye / Chalazion — hordeolum — hot compress, consider antibiotics if spreading
Preseptal Cellulitis — orbital cellulitis precursor — oral antibiotics, monitor closely

Visual Acuity Assessment — Nursing Role

👁

VA Testing Protocol

Document VA BEFORE any treatment (except irrigation in chemical burns)

Snellen Chart — 6m; each eye tested separately; record as 6/6, 6/12 etc.
Pinhole Test — if VA improves = likely refractive, not pathological
Counting Fingers (CF) — document at what distance
Hand Movements (HM) — can patient detect waving
Light Perception (LP) / No LP (NLP) — NLP = worst prognosis indicator

Documentation Points

Test each eye separately; record with and without glasses
Use pinhole for all reduced VA
Note if unable to cooperate (pain/distress) and why
Record time; in chemical burns: VA AFTER irrigation

Red Eye Differential Diagnosis

🔴

Distinguishing Features at Triage

Feature	Conjunctivitis	Keratitis	Iritis/Uveitis	AAOG
Pain	Gritty, mild	Moderate–severe, FB sensation	Deep ache, photophobia	SEVERE, periorbital
Vision	Normal or mildly blurred	Reduced if central	Mildly reduced	Markedly reduced, halos
Discharge	Yes (watery/purulent)	Watery/mucoid	None or minimal	None
Redness Pattern	Diffuse conjunctival	Circumcorneal (ciliary)	Circumcorneal (ciliary)	Circumcorneal + diffuse
Pupil	Normal	Normal or small	Small, irregular	Fixed, mid-dilated
IOP	Normal	Normal or slightly raised	Normal or low	Very high (>40 mmHg)
Cornea	Clear	Opaque/staining	May have KPs	Hazy/steamy
Nausea/Vomiting	No	No	Rare	YES — common
Urgency	Semi-urgent	Urgent	Urgent	IMMEDIATE

Pain & Photophobia Assessment

⚡

Symptom Severity Guide

PAIN CHARACTER GUIDES DIAGNOSIS

Gritty/scratchy — foreign body, corneal abrasion, dry eye, blepharitis
Deep aching — uveitis, scleritis — worse at night
Severe periorbital — AAOG, cluster headache mimic
On blinking only — subtarsal foreign body (evert eyelid)
No pain + visual loss — CRAO, retinal detachment, vitreous haemorrhage

PHOTOPHOBIA SEVERITY

Severe photophobia — iritis/uveitis, keratitis, AAOG, meningitis (check neck stiffness)
Moderate photophobia — corneal abrasion, herpetic eye disease
Mild light sensitivity — conjunctivitis, dry eye

Red Flag: Photophobia + Headache + Neck Stiffness

Rule out meningitis immediately — this is not primarily an eye emergency

TRUE OCULAR EMERGENCY — BEGIN IRRIGATION IMMEDIATELY

Do NOT wait for full history, triage, or doctor review. START IRRIGATION NOW. Every second causes more damage. Permanent blindness can occur within minutes.

Alkali vs Acid Burns

⚠ Alkali Burns — MORE DANGEROUS

Liquefactive necrosis — penetrates deeply, continues to damage hours after exposure

Lime / Calcium hydroxide — plaster, cement, whitewash (extremely common in GCC construction)
Ammonia — cleaning products, fertilisers
Caustic soda (sodium hydroxide) — drain cleaners, soap making
Lye — industrial alkalis
Penetrates through cornea to anterior chamber, iris, lens within minutes
pH may appear to normalise then rebound — recheck pH 5 min after stopping irrigation

● Acid Burns — Still Serious

Coagulative necrosis — proteins coagulate forming a barrier, somewhat self-limiting

Sulfuric acid — car batteries, industrial
Hydrofluoric acid — EXCEPTION: penetrates like alkali — extremely dangerous
Hydrochloric acid — pool chemicals, industrial
Protein coagulation may limit penetration depth
Still causes significant corneal damage — irrigate immediately regardless

Irrigation Protocol

💧

Immediate Copious Irrigation

Anaesthetic drops first — oxybuprocaine/proxymetacaine to allow cooperation
Remove contact lenses — if present, remove immediately. Chemical can be trapped beneath lens.
Irrigate with at least 2 litres — normal saline preferred; tap water acceptable if saline unavailable
Morgan lens if available — insert and connect to IV saline bag for hands-free continuous irrigation
Evert upper eyelid — lime particles hide in upper fornix — evert, sweep with cotton bud, irrigate fornices
Direct stream into medial canthus — irrigate from medial to lateral corner
Have patient look in all directions — ensures fornices are thoroughly irrigated

pH Testing Protocol

Goal pH: 7.0 – 7.4
Test pH in lower fornix with pH paper/strip
Continue irrigation if pH is not neutral
CRITICAL: Wait 5 minutes AFTER stopping irrigation — then recheck pH. Alkali can rebound.
Only safe to stop when pH remains 7.0–7.4 after 5-minute wait
Document: time started, volume used, pH readings, time stopped

Lime/Cement Particles

Must physically remove ALL particles from fornices before/during irrigation. Particles continue releasing alkali. Use cotton bud to sweep upper and lower fornix under topical anaesthetic.

Roper-Hall Classification & Management

▶

Chemical Burn Grading

Grade	Cornea	Limbal Ischaemia	Prognosis	Management
I	Epithelial damage, clear stroma	None	Excellent	Outpatient — antibiotics, lubricants
II	Hazy cornea — iris visible	<1/3	Good	Outpatient/short stay — steroids, VitC
III	Stromal haze — iris obscured	1/3–1/2	Guarded	Admit — intensive topical, amniotic membrane
IV	Opaque — iris/pupil not visible	>1/2 (white)	Poor	Admit — intensive + surgery likely

Limbal Ischaemia = Severity Marker

Blanching of the limbus (cornea-sclera junction) indicates damage to limbal stem cells. Extensive ischaemia = severe prognosis. Grade III–IV requires hospital admission.

Interactive Chemical Eye Burn First Aid Protocol

⚠ Chemical Eye Burn — Step-by-Step Protocol

Click through each step. Start the irrigation timer immediately.

Irrigation Timer

00:00

Minimum 20–30 minutes continuous irrigation

Step 1 of 8

IRRIGATE IMMEDIATELY

DO NOT wait for doctor. START IRRIGATION NOW.

If topical anaesthetic available: instil oxybuprocaine/proxymetacaine 0.4% to improve cooperation
Position patient supine or leaning forward
Use normal saline (minimum 2 litres) or tap water if saline unavailable
Direct stream gently into the eye — from medial corner outward
Ensure irrigation is actively running through the eye — not just over eyelids

START THE TIMER above as soon as irrigation begins. Document the time irrigation started.

Step 2 of 8

Remove Contact Lenses

While irrigating, determine if patient wears contact lenses
If yes — remove contact lenses immediately. Chemical can be trapped under the lens continuing to damage the cornea.
Use gloved fingers or a lens remover. If patient can remove themselves, instruct them to do so.
Continue irrigation without interruption while removing lenses if possible

Do NOT pause irrigation to remove lenses — remove during irrigation.

Step 3 of 8

Use Morgan Lens (if available)

Morgan lens provides hands-free, continuous, effective irrigation
Insert under topical anaesthetic — place like a contact lens
Connect to 1 litre bag of normal saline via IV giving set
Run at gravity drip — ensures constant flow through all parts of the conjunctival sac
If Morgan lens not available — continue with manual irrigation using IV giving set, 50ml syringe, or eye bath

Morgan lens significantly improves irrigation effectiveness. Use when available and trained to do so.

Step 4 of 8

Evert Eyelids and Irrigate Fornices

Evert the upper eyelid — chemical particles (especially lime/cement) hide in the upper fornix
Use cotton bud/applicator to gently sweep the upper and lower fornix to remove particles
Direct irrigation into the superior and inferior fornices specifically
Ask patient to look up, down, left, right to ensure all areas are irrigated
Visible white particles (lime/cement) must be physically removed — irrigation alone is insufficient

For lime/cement burns: particle removal is critical. Continue irrigation after particle removal.

Step 5 of 8

Check pH Every 5 Minutes

Place pH paper/strip in the lower conjunctival fornix while still irrigating
Target pH: 7.0 – 7.4 (neutral)
If pH < 7.0 (acid) or > 7.4 (alkali): CONTINUE IRRIGATING
Document each pH reading with timestamp
For alkali burns: expect to need significantly more than 2 litres of saline

pH not neutral after 2 litres? Obtain more saline and continue. There is no maximum volume — continue until pH is neutral.

Step 6 of 8

Continue Irrigation Until pH Remains Neutral

Stop irrigation ONLY when pH reads 7.0–7.4
WAIT 5 MINUTES after stopping irrigation — then recheck pH
If pH rebounds away from neutral: resume irrigation — alkali has continued to leach from deeper tissues
Only safe to stop permanently when pH remains 7.0–7.4 after the 5-minute wait
Minimum recommended irrigation time: 20–30 minutes for alkali; 15–20 minutes for acid

CRITICAL: The 5-minute pH recheck after stopping is mandatory for alkali burns. A rebounding pH means continuing chemical damage.

Step 7 of 8

Slit Lamp Examination & Assessment

AFTER irrigation is complete and pH is stable: assess with slit lamp (ophthalmologist/trained nurse)
Assess corneal clarity, epithelial defect (fluorescein staining), limbal ischaemia
Document Roper-Hall grade (I–IV)
Visual acuity — document post-irrigation VA
Check for retained particles in the fornices
Assess anterior chamber for reaction

Grade 3–4 burns: immediate ophthalmology review and hospital admission. Grade 1–2: urgent ophthalmology clinic next working day.

Step 8 of 8

Document and Refer

Document: time of chemical exposure, chemical agent and concentration (if known), time irrigation started, total volume irrigated, pH readings with times, VA pre/post, Roper-Hall grade
Grade I–II: Urgent ophthalmology outpatient referral
Grade III–IV: Immediate ophthalmology inpatient admission
All alkali burns: ophthalmology review same day
Start topical antibiotics as prescribed to prevent secondary infection
Analgesia as prescribed
Safety netting: return immediately if worsening pain, vision loss, photophobia

AAOG — OPHTHALMIC EMERGENCY

Acute Angle Closure Glaucoma causes rapid irreversible optic nerve damage. IOP often exceeds 50 mmHg (normal <21 mmHg). Permanent visual loss can occur within hours without treatment.

Clinical Features

🔴

Symptoms

Severe unilateral eye pain — often described as the worst pain experienced
Nausea and vomiting — commonly misdiagnosed as GI emergency initially
Blurred vision — with coloured halos around lights (corneal oedema)
Headache — ipsilateral frontal/orbital headache
Visual loss — varies from mild to severe

🔍

Signs

Fixed mid-dilated pupil — 4–6 mm, oval, non-reactive to light
Rock hard eye on palpation — compare to fellow eye (firm globe)
Ciliary flush — circumcorneal injection (redness around the corneal margin)
Hazy/steamy cornea — corneal oedema from high IOP
Shallow anterior chamber — seen on slit lamp

IOP — Understanding the Numbers

🅾

Intraocular Pressure Reference

0 mmHg21 mmHg40 mmHg60 mmHg+

Normal (<21) Elevated (21–40) AAOG (>40, often >50)

Normal IOP: 10–21 mmHg
Ocular hypertension: 21–30 mmHg — monitor, treat if risk factors
AAOG typical: 40–70+ mmHg — ophthalmic emergency
Measured by: Goldmann applanation tonometry (gold standard) / iCare rebound tonometer / Tono-pen
Nursing role: iCare tonometry can be performed by trained nurses

Immediate Treatment Protocol

⚡

Emergency Management

MEDICATIONS (as prescribed by doctor)

Acetazolamide (Diamox) — 500mg IV or PO — carbonic anhydrase inhibitor — reduces aqueous humour production
Topical Pilocarpine 2% — miotic — constricts pupil — opens trabecular meshwork angle — apply to BOTH eyes
Topical Timolol 0.5% — beta blocker — reduces aqueous production — check no asthma/COPD contraindication
IV Mannitol 20% — 1–2 g/kg over 45 min — osmotic agent — if IOP severely elevated and unresponsive
Antiemetics — for nausea/vomiting (metoclopramide)

CONTRAINDICATED — NEVER USE IN AAOG

Atropine — dilates pupil — WILL WORSEN AAOG catastrophically
Any mydriatic (pupil-dilating) agent — tropicamide, cyclopentolate, phenylephrine
Check ALL medication charts — antihistamines, some antidepressants can dilate pupils

Definitive Treatment

Laser Peripheral Iridotomy (LPI) — creates hole in iris — equalises pressure between anterior and posterior chambers — definitive treatment
Fellow eye: prophylactic LPI recommended — bilateral risk
Surgical iridectomy if laser unavailable

GCC Nursing Relevance

🌎

AAOG in the GCC Population

Higher prevalence in South Asian populations — Indian, Sri Lankan, Bangladeshi workers (largest migrant group in GCC) have anatomically narrower anterior chamber angles
Hyperopia (long-sight) — smaller eyes — higher risk of angle closure
May be misdiagnosed as migraine or GI emergency due to nausea/vomiting — check eyes in all acute severe unilateral headache + nausea presentations
Language barriers common — use visual aids and interpreter services

Central Retinal Artery Occlusion (CRAO)

⚠

CRAO — Stroke of the Eye

PRESENTATION

Sudden, painless, severe, unilateral visual loss — often described as a curtain falling or light switching off
Vision reduced to counting fingers, hand movements, or light perception only
May have prodromal amaurosis fugax (transient visual loss)
RAPD — relative afferent pupillary defect on swinging torch test

FUNDOSCOPY FINDINGS

Cherry red spot at macula — classic finding — normal foveal choroidal supply visible against pale retina
Pale/white ischaemic retina — retinal oedema
Cattle-truck pattern (box-car segmentation) in retinal arteries — sluggish/interrupted blood column
Arteries thin and attenuated

3-Hour Treatment Window

Evidence is limited but treatment is attempted within 3 hours of onset. CRAO = stroke equivalent — begin stroke workup immediately.

Immediate Measures (Limited Evidence)

Ocular massage — intermittent gentle pressure to lower IOP and dislodge clot
IOP-lowering medications — acetazolamide, timolol
CO2 rebreathing — vasodilation (paper bag method — limited use)
Paracentesis — anterior chamber tap by ophthalmologist

Urgent Stroke Workup

CRAO = stroke equivalent — cardioembolic cause must be excluded
ECG (AF), Carotid doppler, Echo
Bloods: FBC, ESR/CRP (giant cell arteritis in elderly)
Neurology/stroke team review

Central Retinal Vein Occlusion (CRVO)

●

CRVO

Painless visual loss — typically less severe and acute than CRAO
Vision varies — may be mild or severely affected
Fundoscopy: flame haemorrhages in ALL 4 quadrants — "blood and thunder" appearance
Disc oedema, dilated tortuous veins
Cotton wool spots

Risk factors: hypertension, diabetes, glaucoma, hyperlipidaemia
Complications: neovascularisation, vitreous haemorrhage, neovascular glaucoma
Management: anti-VEGF injections, laser photocoagulation, treat underlying systemic disease
Urgent ophthalmology referral — not immediate emergency unless CRVO + neovascular glaucoma

Retinal Detachment

⚠

Retinal Detachment — Surgical Emergency

SYMPTOMS (in order of development)

Flashes of light (photopsia) — vitreous traction on retina — often peripheral
Floaters — sudden onset, new, or dramatic increase — vitreous debris or blood
Curtain/shadow across vision — actual detachment — visual field loss corresponding to detachment location

Macula-On vs Macula-Off

Macula-on: central vision intact — truly urgent — surgery within hours
Macula-off: central vision involved — surgery within 24 hours — prognosis worse

Nursing Actions for Suspected Retinal Detachment

Do NOT apply eye pad over the eye
Advise patient to keep head still — do not read or watch TV
For inferior detachment: position patient supine to keep macula attached
Nil by mouth if macula-on — patient may need emergency surgery
Urgent ophthalmology referral immediately
Do NOT dilate pupil without ophthalmology instruction

Vitreous Haemorrhage

●

Vitreous Haemorrhage

Sudden painless visual loss — floaters, cobwebs, shadows, reduced VA
Caused by: proliferative diabetic retinopathy (most common), retinal detachment, trauma, retinal tear
Fundus view obscured — cannot see retinal details through blood
B-scan ultrasound — essential when fundus cannot be visualised — rules out retinal detachment underneath

Management: head elevation at night to allow blood to settle inferiorly, stop anticoagulants if safe to do so
Avoid aspirin/NSAIDs unless essential
Vitrectomy surgery if no spontaneous clearance within 3 months
GCC relevance: DM prevalence highest in world — diabetic vitreous haemorrhage is common presentation in GCC EDs

GCC Eye Disease Burden

⚠

Diabetic Retinopathy

The GCC has among the highest diabetes prevalence in the world (UAE, Saudi Arabia, Kuwait — 15–25% adult prevalence). Diabetic retinopathy is the leading cause of preventable blindness in working-age adults across the GCC.

Background DR, pre-proliferative, proliferative DR stages
Diabetic macular oedema — leading cause of central vision loss in DM
Proliferative DR — neovascularisation, vitreous haemorrhage, traction retinal detachment
Annual diabetic eye screening is standard of care — nurse-led screening programmes expanding in GCC

●

Glaucoma in GCC

Primary open-angle glaucoma — silent, progressive — often advanced at presentation in GCC (late healthcare-seeking behaviour)
Acute angle closure glaucoma — higher prevalence in South Asian expat worker population (Indian, Pakistani, Sri Lankan, Bangladeshi)
Estimated 50% of glaucoma in GCC is undiagnosed
Regular IOP screening important in diabetic clinic, occupational health settings

●

Pterygium

Fibrovascular growth from conjunctiva onto cornea. Highly prevalent in GCC due to:

Intense UV radiation — year-round sunshine, limited shade
Dust and sand exposure — occupational and environmental
Outdoor workers — construction, agriculture, security — highest risk
Treatment: lubricating drops, UV-protective sunglasses, surgical excision if encroaching on visual axis
Nursing role: UV protection education for all outdoor workers

●

Trachoma — Near Eradicated

Historically significant cause of blindness in the Middle East — near eradicated in GCC via WHO SAFE strategy
May still be seen in newly arrived migrants from endemic regions (Sub-Saharan Africa, South Asia)
Awareness maintained for imported cases

Occupational Eye Injuries in GCC

🏗

Construction Sector — High Risk

Grinding and drilling — metallic foreign bodies — highest volume of corneal FB presentations in GCC emergency departments
Cement/lime chemical burns — alkaline — extremely common — construction workers mixing cement without eye protection
Welding arc eye — photokeratitis — UV radiation from welding without adequate eye protection — bilateral severe pain, photophobia 6–12 hours after exposure
Wood/dust foreign bodies — carpentry, fit-out trades
Power tool projectile injuries — penetrating trauma risk

PPE Education — Nursing Opportunity

Safety goggles or face shields mandatory for grinding, drilling, chemical handling
Welding masks with appropriate shade filter
UV-protective sunglasses for outdoor workers
GCC labour law mandates PPE — enforcement variable on smaller sites
Occupational health nurse role — safety visits, PPE training, eye screening

Sand and Dust in GCC

🌊

Desert Environment Eye Issues

Grit/sand FBs — more common than temperate climates; fine desert sand can cause multiple superficial FBs simultaneously
Dust storms (haboob) — mass-casualty eye presentations possible after major events
Dry eye syndrome — very prevalent in GCC — air conditioning, low humidity, heat; corneal staining from dry eye can mimic keratitis
Management: lubricating drops, artificial tear education, humidifiers, avoid direct AC airflow onto eyes

Traditional Eye Treatments

●

Kohl (Surma) — Cultural Awareness

Kohl — Lead Toxicity Risk

Traditional kohl (surma, kajal) is widely used in GCC, South Asia, and North Africa. Traditional preparations contain lead sulfide (galena) — regular use, especially in infants, causes elevated blood lead levels and corneal toxicity.

Applied to inner eyelid margin cosmetically and as traditional remedy — risk of abrasion, infection, lead absorption
Culturally sensitive nursing education: advise caution especially for infants, cease use if eye symptoms develop
Document traditional remedy use in ophthalmic history

GCC Ophthalmology Centres

🏥

Major Regional Centres

Moorfields Eye Hospital — Dubai, UAE — UK-quality private specialist eye hospital. Ophthalmology nursing roles, orthoptist nurse roles. Internationally recognised training centre.
Abu Dhabi Eye Hospital (ADEH) — Dedicated public eye hospital — largest in UAE government sector. Full subspecialty services.
King Khaled Eye Specialist Hospital (KKESH) — Riyadh, Saudi Arabia — Major regional referral centre. World-class ophthalmic surgery and research.
Hamad Medical Corporation — Eye Care Centre, Qatar — Primary eye emergency and specialist care in Qatar.

Ophthalmology Nursing in GCC — Career Note

Growing speciality — significant demand for trained ophthalmic nurses
Well-remunerated positions in private sector (Moorfields Dubai, NMC Eye Care, Magrabi Hospitals)
Orthoptist nurse roles — visual assessment, strabismus clinics
Diabetic retinopathy screening nurse — rapidly expanding
Operating theatre scrub/scout nurse for cataract, vitreoretinal surgery
UK RCOP/BIOS postgraduate qualifications valued

Camel Encounters — Rural Context

Rare but documented in rural GCC farm/Bedouin settings. Camel kicks/bites cause periorbital trauma, ruptured globe, orbital fractures. Eye shield + urgent ophthalmology/maxillofacial referral.

GCC Nursing: Ophthalmic Emergencies & Eye Care

⚠ Chemical Eye Burn — Step-by-Step Protocol

Morgan Lens (Preferred)

IV Giving Set (Improvised)

Undine / Eye Bath