SAEM Clinical Images Series: Two Pupils for the Price of One


A 24-year-old female with no pertinent PMHx presents to the ED with a chief complaint of eye pain. She reported a 10-day history of worsening right eye pain following being punched in that eye. She had been managing her pain with ice and had not taken any OTC medications. Her mom convinced her to go to the ED and she first went to an outside hospital, but was referred to come to our institution. She endorsed photophobia and blurry vision but denied double vision. She further noted occasional left-sided headaches.

Vitals: Within normal limits

General: The patient is alert and conversant. No apparent distress.

HEENT: NC, AT. Mucous membranes moist. Neck supple. Minimal pain with EOM. No double vision in right eye. Right eye discoloration at superior portion. Divided abnormal pupil. Mild superior periorbital swelling. Visual acuity: Right – 20/400, Left – 20/25

CV: Regular rate and rhythm.

Resp: Clear to auscultation bilaterally.

Abd: Soft, non-tender, non-distended.

Neuro: Alert. Motor and sensation grossly intact.

MSK: Moves all extremities, no joint pain or tenderness.

Skin: No obvious rashes or skin lesions.


This is traumatic iridodialysis. It is typically related to significant blunt trauma to the eye that pulls the iris away from the ciliary body at the scleral spur [1]. That is what causes the split appearance or “two pupil” phenomenon.

Take-Home Points

  • Whenever you have a two-pupil phenomenon consistent with traumatic iridodialysis, the differential should always include penetrating injury to the globe, globe rupture, scleral rupture, hyphema, and lens dislocation. These additional findings may warrant urgent surgical repair or close monitoring of IOP. [2]
  • Consider bedside ultrasound to rule out posterior pathology (retinal detachment, vitreous hemorrhage, etc.).
  • Always refer to Ophthalmology, more urgently if the trauma was recent vs multiple days out (as in this case).
  • Knoop KJ, Palma JK. Iridodialysis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021.
  • Gurwood AS. Cut at the root. Review of Optometry. Published November 19, 2012. Accessed January 2023.

By |2024-02-25T20:54:51-08:00Mar 1, 2024|Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Retrobulbar Spot Sign


A 59-year-old male with no known past medical history other than an incidental abdominal aortic aneurysm presented with sudden onset, painless vision loss in his left eye. The patient was watching TV two days prior when he saw a “brightness” in his left eye and then progressive blurriness until his vision faded away, all occurring within the span of a minute. At the time of presentation, he only sees a speck of light from that eye. He denied associated pain, flashes, floaters, jaw claudication, the sensation of a “curtain falling”, prior vision problems, or a history of blood clots.

Eyes: Eyelids and lashes normal. Visual acuity: 20/30 OD, Light Perception OS. EOMI. PERRL. OD visual fields intact. Afferent Pupillary Defect OD. Normal conjunctiva. IOP 16 OD, 14 OS. Otherwise CN 3-12 intact.

Complete blood count (CBC): Within normal limits

Basic metabolic panel: Creatine 1.3 (unknown baseline)

ESR: Unmarkable

Central Retinal Artery Occlusion (CRAO) is an ocular emergency that presents as acute painless monocular vision, caused by ischemia and infarction to the retina via thromboembolic disease to the central retinal artery. It requires immediate consultation with ophthalmology as well as neurology as it is considered a stroke equivalent.

The case described above and several previously published case studies highlight the utility of POCUS in identifying CRAO via the retrobulbar spot sign (RBSS) within the optic nerve in a rapid, non-invasive manner that can be done prior to waiting for dilation for a fundoscopy exam. This has the potential to expedite consultations with specialty teams and treatment.

Several studies also reveal the potential of POCUS to predict the etiology of CRAO (arterio-arterial embolization vs cardio-embolic vs vasculitis) and thus to predict the success of thrombolytic treatment in CRAO. In a prospective monocenter study of 46 patients with ophthalmologically confirmed CRAO, embolism from large artery atherosclerosis (LAA, i.e. carotids or aortic arch) was the etiology in 27 patients, cardioembolic in 10 patients, vasculitis in 5 patients, and unknown in 4 patients. Out of the LAA patients, 59% had RBSS compared with only 20% in cardioembolic and 0% in the vasculitis patients. Within the 11 patients that underwent thrombolysis, statistically significant visual improvement occurred in all 4 patients with RBSS negative CRAO, while the 7 patients with RBSS positive CRAO had persistent visual impairment with persistent occlusion of their arteries. This study concludes that their results support the hypothesis that RBSS is seen due to calcium deposits that will not be dissolved with thrombolysis. Another small single-center German study points out the utility of seeing RBSS as 100% specific for an embolic cause of CRA, excluding temporal arteritis from the differential.

Take-Home Points

  • POCUS can guide us in diagnosing a patient with painless vision loss prior to more time-consuming fundoscopy exam.
  • Stroke workup for CRAO is necessary, and don’t forget about secondary prevention/risk stratification which must be part of the management.
  • RBSS may predict poor response to systemic thrombolysis.

  • Ertl M, Altmann M, Torka E, Helbig H, Bogdahn U, Gamulescu A, Schlachetzki F. The retrobulbar “spot sign” as a discriminator between vasculitic and thrombo-embolic affections of the retinal blood supply. Ultraschall Med. 2012 Dec;33(7):E263-E267. doi: 10.1055/s-0032-1312925. Epub 2012 Sep 21. PMID: 23023446.
  • Nedelmann, Matt et al. “Retrobulbar Spot Sign Predicts Thrombolytic Treatment Effects and Etiology in Central Retinal Artery Occlusion” American Heart Association (AHA). Stroke. 2015;46:2322–2324
  • Smith, Austin T et al. “Using the Retrobulbar Spot Sign to Assist in Diagnosis and Management of Central Retinal Artery Occlusions.” Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine vol. 39,1 (2020): 197-202. doi:10.1002/jum.15073

By |2024-01-28T21:19:20-08:00Jan 29, 2024|Ophthalmology, SAEM Clinical Images, Ultrasound|

SAEM Clinical Images Series: Dangerous Eye Drainage

orbital abscess

A 32-year-old man with a history of traumatic globe rupture from a stab wound two months ago, status post repair, presented to the emergency department for worsening right eye pain and green malodorous drainage for the past three days. These symptoms started when he got a fleck of sawdust in the right eye about four days prior to presentation, which he was able to brush out with his finger. He described the pain as severe, throbbing, constant, and non-radiating. He had been unable to open the right eyelid for three days, both due to pain and from the thick sticky discharge that adhered his eyelids together. He reported that his vision had been normal before these symptoms started. On review of systems, he reported nausea that started on the day of presentation but otherwise denied any vision loss or pain in the other eye.

General: Nontoxic appearing but seemed quite uncomfortable.

Eye: On inspection, he had substantial right upper and lower eyelid swelling and erythema, with a green discharge dripping from the palpebral fissure. There was a well-healed scar on the bottom eyelid. The lateral canthus appeared inferiorly displaced. The patient was unable to open his right eye actively, and was unable to tolerate passive opening due to severe discomfort, despite pain medication.

White blood cell (WBC) count: 9.1 x 10^3 /uL with 80.4% neutrophils

Complete metabolic panel (CMP): Within normal limits

Procalcitonin:<0.05 ng/mL

Lactate: 1.4 mmol/L

Cultures from the eye revealed penicillin-sensitive Streptococcus pneumoniae.

Pain with extraocular movements should be present in orbital cellulitis due to inflammation of the structures deep within the orbit. Although not sensitive, proptosis, leukocytosis & fever, chemosis, or any visual impairment should raise concern for orbital cellulitis.

In this patient, displacement of the lateral canthus likely represents a mass effect from his orbital abscess. This abscess is seen lateral to the globe on imaging. On ultrasound, it appears as a heterogeneous isoechoic collection that abuts the right globe. A hyperechoic structure between the orbit and this collection with shadowing raises the possibility of a foreign body. Debris is also visible throughout the right globe and within the anterior chamber. On CT scan, the abscess is described as a rim-enhancing fluid collection that adheres to the lateral rectus muscle. The hyperdense foreign body is again seen on CT, as well as a small focus of air within the anterior chamber.

Take-Home Points

  • Orbital abscess is an uncommon but vision-threatening ocular emergency, which can come from traumatic injury to the globe (as with this case), sinus/nasal infections, or as a complication of dental procedures.
  • The most common organisms responsible for orbital abscesses are Streptococci species (including Strep. pneumoniae and Strep. pyogenes), Staphylococcus aureus (including methicillin-resistant Staph. Aureus), and Pseudomonas aeruginosa.
  • Surgical management is necessary in almost all cases of orbital abscess, with just under 50% of all patients achieving complete visual recovery.

  • Krohel GB, Krauss HR, Winnick J. Orbital abscess. Presentation, diagnosis, therapy, and sequelae. Ophthalmology. 1982 May;89(5):492-8. doi: 10.1016/s0161-6420(82)34763-6. PMID: 7099569.
  • Zawadzki T, Komisarek O, Pawłowski J, Wojtera B, Bilska-Stokłosa J, Osmola K. Orbital Abscess-Two Case Reports with Review. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 2):1334-1343. doi:10.1007/s12070-021-02486-z

By |2023-10-22T20:48:41-07:00Oct 23, 2023|HEENT, Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Contact Your Nearest Ophthalmologist


A 29-year-old female with a past medical history of migraine headaches presented to the emergency department (ED) for several hours of bilateral eye pain, redness, and decreased visual acuity. The patient is a contact lens wearer. The night prior to presentation at 18:00, the patient inserted her contacts that she had washed and soaked in a hydrogen peroxide (H2O2) cleaning solution. She removed the contacts five hours later at 23:00, at which time she noted her eyes to feel drier than normal but did not note significant pain with removal, significant trauma, or a partial contact removal. For the eye dryness and mild irritation, she rinsed her eyes with her contact solution. She woke up the following day at 6:00 with severe, bilateral eye pain, blurry vision, and difficulty opening her eyes due to pain. She again washed her eyes with contact solution which resulted in worsening pain while also noting a “fizzing” sensation in her eyes which prompted her presentation to the ED at 10:00. She denied any foreign body sensation, known trauma, or experiencing similar symptoms previously.

General: Mildly uncomfortable appearing

Eyes: Bilateral corneal injection with mild tearing. No foreign body on lid eversion. Uncorrected visual acuity of 20/200 in the right eye and 20/30 in the left eye. Extra-ocular movements intact. Right eye pressure measured 18 mmHg and left eye 17 mmHg. pH 7.0 in both eyes.

Fluorescein uptake represents defects in the cornea that allow for this dye to pool. For this case, this represents trauma caused by contact lens removal as the uptake covers the areas where contacts are placed.

Given the location and size of these defects, antibiotic drops should be promptly initiated, and prompt ophthalmologic evaluation should be obtained.

Take-Home Points

  • Corneal abrasions can occur in both eyes at once.
  • Timely administration of antibiotic drops and ophthalmology evaluation is crucial to prevent progression to corneal ulcer and the need for corneal transplant.

  • Cope JR, Collier SA, Rao MM, Chalmers R, Mitchell GL, Richdale K, Wagner H, Kinoshita BT, Lam DY, Sorbara L, Zimmerman A, Yoder JS, Beach MJ. Contact Lens Wearer Demographics and Risk Behaviors for Contact Lens-Related Eye Infections–United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Aug 21;64(32):865-70. doi: 10.15585/mmwr.mm6432a2. PMID: 26292204; PMCID: PMC5779588.
  • Stapleton F, Bakkar M, Carnt N, Chalmers R, Vijay AK, Marasini S, Ng A, Tan J, Wagner H, Woods C, Wolffsohn JS. CLEAR – Contact lens complications. Cont Lens Anterior Eye. 2021 Apr;44(2):330-367. doi: 10.1016/j.clae.2021.02.010. Epub 2021 Mar 25. PMID: 33775382.
  • U.S. Food and Drug Administration. (2022, August 16). Hydrogen Peroxide Solution. Hydrogen Peroxide Solution | FDA. Retrieved September 5, 2022, from

By |2023-09-05T15:24:04-07:00Sep 11, 2023|Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: My Eye Looks Different


A 29 year-old-male with a past medical history of left eye enucleation secondary to a gunshot wound several years prior presents to the Emergency Department (ED) for blurry vision, redness, and concern for a deformity to his right eye. The patient states symptoms started 2-3 months ago and he initially thought symptoms were due to allergies and recalls rubbing his eye a lot. Over the past 3-4 days, he noticed an acute decline in his vision with what the patient describes as a “cloudy bump” appearing during that time. The patient normally does not wear contacts or corrective lenses but states his vision is very blurry and he is now having difficulty reading. He also reports photophobia and mild eye pain. Review of systems is negative for any fevers, headache, eye discharge, or any recent falls or trauma.

Vitals: BP 125/83; Pulse 70; Temp 97.6 F (36.4 C); Resp 17; SpO2 100%

Constitutional: No acute distress, lying in stretcher comfortably.

Head: No visible traumatic injuries. No peri-orbital edema or facial swelling.


  • OD: Edematous cone-shaped protrusion with central haziness. V-shaped deformity to lower lid margin noted on downward gaze. The patient reports no pain when performing extraocular movement testing which is intact and pupil is reactive to light. Visual fields intact. There is no fluorescein uptake upon Wood’s Lamp exam and IOP is 18. VisualAcuity OD 20/200.
  • OS: Eye prosthesis in place.

Nose: No foreign bodies.

Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.

Neck: Normal range of motion.

Corneal hydrops secondary to keratoconus.

Keratoconus is a degenerative, multifactorial, non-inflammatory disorder of the cornea that causes bilateral thinning of the cornea and distorted vision. The corneal thinning leads to a structural weakness in the collagen fibers that causes the characteristic bulging, “cone-shaped” cornea. If the thinning is significant enough, a break in collagen fibers and Descemet’s membrane lead to sudden edema which appears as a corneal opacification. This complication is known as corneal hydrops and causes sudden eye pain and decreased visual acuity. Patients with keratoconus present in young adulthood with progressive blurry or distorted vision. Risk factors include connective tissue disorders and Down syndrome as well as a familial history of keratoconus. There is also a risk in patients with a history of eye rubbing as was the case with this patient. The initial treatment for keratoconus is corrective eyewear for refractive correction.

The clinical hallmark of keratoconus is the cone-like protrusion of the cornea. The bulging may eventually lead to “Munson’s sign”, a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward that is seen in advanced keratoconus.

Take-Home Points

  • Suspect keratoconus in patients with a history of constant eye rubbing, developmental delay (i.e. Down Syndrome), and in patients with connective tissue disorders.
  • Munson’s Sign is a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward.
  • Initial treatment of keratoconus is conservative management with prompt ophthalmology follow-up.

  • V. Mas Tur, C. MacGregor, R. Jayaswal, D. O’Brart, N. MaycockA review of keratoconus: Diagnosis, pathophysiology, and genetics Surv Ophthalmol, 62 (6) (2017), pp. 770-783
  • Gold J, Chauhan V, Rojanasthien S, Fitzgerald J. Munson’s Sign: An Obvious Finding to Explain Acute Vision Loss. Clin Pract Cases Emerg Med. 2019 Jul 8;3(3):312-313. doi: 10.5811/cpcem.2019.5.42793. PMID: 31403106; PMCID: PMC6682229.
  • Gialousakis, John P. “Management of Acute Corneal Hydrops in a Patient with Keratoconus: a Teaching Case Report.” The Journal of the Association of Schools and Colleges of Optometry, vol. 45, 2020.
  • Greenwald MF, Vislisel JM, Goins KM. Acute Corneal Hydrops. August 3, 2016; Available from:
  • Stack L, Sheedy C, Bales B. Corneeal Hydrops: A Complication of Keratoconus. Visual Diagnosis Ophthalmology. Published 2015 Dec 11. Available from:

By |2023-04-05T14:07:32-07:00Apr 17, 2023|HEENT, Ophthalmology, SAEM Clinical Images|

Trick of the Trade: Antibiotic ointment for removal of artificial nail glue from eyelids

A bottle of nail glue and timolol eye drops (reproduced with permission from BMJ Publishing Group Ltd [1])

You are working a busy shift in your department’s fast track area and sign up for a patient with a complaint of “eye pain.” The patient is a fan of glue-on nails and mistook her nail glue bottle for her eyedrops. Now she is unable to open her eyelid for the exam and you struggle to open it yourself. You want to avoid cutting the adhered eyelashes and wonder if there’s a better solution.

Background rise of artificial, press-on nails

Artificial acrylic or “press-on” nails were first invented in the 1950s; however, they did not gain in popularity until the 1980s as nail art became a trend [2]. Shortly thereafter, they fell out of style until a resurgence occurred with the COVID pandemic forcing the closure of nail salons. Compared to pre-pandemic values, Google searches for “press on nails” increased 300% [3]. Application of most nails requires nail glue, which often contains a mixture of alcohol, cyanoacrylate (superglue), or photo-bonded methacrylate [4].

Nail glue complications

Use of nail glue at home can result in adverse exposures with the most common location being the eye [5]. Because nail glue is often packaged in small containers identical to eye drop bottles, patients can mistake the nail glue for ophthalmic drops — especially those with visual impairment [6]. This exposure was first described in the medical literature in 1982 and has been described many times since despite repeated calls for manufacturers to modify the bottles to be safer [1].

In the presence of water, cyanoacrylate rapidly polymerizes, leading to the bonding effect [5]. If the glue gets into a person’s eye, reflexive blinking pushes the glue to the eyelid margins resulting in the eyelashes or eyelid margins sticking together [5], also known as inadvertent tarsorrhaphy. Methods to open the eyelids include removal of glue with forceps, removal or cutting of the eyelashes, or soaking the eye for hours to days with a moist gauze [1, 6, 7].

Although the most successful solvent to dissolve dried glue is acetone, this can cause corneal and conjunctival injuries [8]. The effectiveness of other solvents has been debated in the literature with mixed reports of efficacy [9].

Trick of the Trade: Apply petroleum-based topical antibiotic ointment

Our personal experience managing several of these cases suggests that a petroleum-based topical antibiotic ointment, such as Bacitracin, can help loosen the glue bond. It is an inexpensive option with minimal harm to fix inadvertent eyelid adhesion from nail glue (or other superglue). It is worth trying before attempting more aggressive techniques.

eyelid nail glue adhesion inadvertent tarsorrhaphy ointment

Before and after application of topical antibiotic ointment to remove inadvertent nail glue causing eyelid adhesion

Materials Needed

  • Bacitracin ointment (1-2 tubes)
  • Cotton-tipped applicatiors (Q-tips)


  1. Apply the topical ointment liberally to the affected eye.
  2. Let rest undisturbed for 15-20 minutes.
  3. Gently pull the eyelids and eyelashes apart.
    • Be careful not to massage the area too vigorously onto the eye itself, as any residual local glue can result in corneal trauma.
    • You can use cotton-tipped applicators to help gently tease the lid margins apart.
  4. Copiously irrigate the eye.
  5. Perform an eye exam to assess for ocular injury.
  6. Consider obtaining an ophthalmology consult.


  1. Yusuf IH, Patel CK. A sticky sight: cyanoacrylate “superglue” injuries of the eye. BMJ Case Rep. 2010;2010:bcr11.2009.2435. doi:10.1136/bcr.11.2009.2435
  2. Quinn J. Not Your ’80s Press-Ons: Why the Press-On Manicure Trend Is a Must-Try. Sunday Edit. Published June 10, 2022. Accessed October 26, 2022.
  3. Google Trends on “press on nails”. Google Trends. Accessed October 26, 2022.
  4. Brambilla E, Crevani M, Petrolini VM, et al. Exposure to Nail and False Eyelash Glue: A Case Series Study. Int J Environ Res Public Health. 2020;17(12):E4283. doi:10.3390/ijerph17124283
  5. Forrester MB. Characteristics of ocular nail glue exposures reported to the National Electronic Injury Surveillance System during 2000-2019. Clin Toxicol Phila Pa. 2021;59(7):633-638. doi:10.1080/15563650.2020.1834115
  6. Samet A, Li DQ, Al-Qahtani A, Arthurs B, El-Hadad C. Nail glue injuries to the eye: assessment of two cases. Can J Ophthalmol. 2022;57(1):e11-e13. doi:10.1016/j.jcjo.2021.04.026
  7. Cohen J. Super Glued Shut. Brown Emergency Medicine. Published Apr 12, 2017. Accessed February 5, 2023.
  8. Reddy SC. Superglue injuries of the eye. Int J Ophthalmol. 2012;5(5):634-637. doi:10.3980/j.issn.2222-3959.2012.05.18
  9. Prouty H, Adams DS, Heard K. Evaluation of Treatments for Cyanoacrylate Eyelash Adhesion Using an In-Vitro Model. Cutan Ocul Toxicol. 2008;27(1):11-14. doi:10.1080/15569520701856732
By |2023-02-06T13:59:27-08:00Feb 8, 2023|Ophthalmology, Tricks of the Trade|

SAEM Clinical Image Series: Snowball Effects

A 13-year-old boy presented to the emergency department with complaints of a right eye injury. Five hours prior to arrival, he was struck directly in the right eye with a snowball resulting in immediate eye pain, localized swelling, some flashes of light in his vision and blurry vision. Prior to arrival, the patient had been seen at an optometry center where puff pressures of his eyes were obtained and the right eye was noted to have an increased intraocular pressure (IOP) of 46 mmHg compared to a pressure of 13 mmHg on the left. He continued to endorse photophobia and mild right eye pain.


  • No bony tenderness or crepitus surrounding the right eye
  • Positive blood fluid level in the anterior chamber
  • EOMI
  • On confrontation of visual fields, the patient was unable to count fingers in all fields on the right but could detect light and movement
  • Red reflex could not be elicited on fundoscopic exam
  • On fluorescein exam, no flow of aqueous humor and no corneal abrasions
  • Tono-Pen IOP measurements were 41mmHg in the right eye, and 27 mmHg in the left eye


The red flags include a history of vision loss and the presence of ocular hypertension with the hyphema. Ophthalmology was emergently consulted for the intraocular hypertension. By the time of evaluation by the specialist, the patient stated that his vision was less blurry and he did not see any spots in his vision. The photos demonstrate progression of the traumatic hyphema from grade IV, to grade II, and then grade I.


The emergent conditions that must be addressed include open globe and intraocular hypertension. Ophthalmology IOP measurements were 14 mmHg bilaterally. Visual acuities were 20/40 on the right and 20/20 on the left. A dilated eye exam with the slit lamp could not fully assess the posterior eye structures due to haziness. A metal eye shield was applied to the patient’s right eye, and he was discharged with cyclopentolate and prednisolone acetate eye drops, and an ophthalmology follow-up appointment within 24 hours. The patient was instructed to be on bed rest with the head of the bed elevated and to avoid straining.



Take-Home Points

  • In traumatic eye injury, pay attention to eye color changes with grade IV hyphema which can be missed unless you compare it to the uninjured side.
  • Look for features of an open globe which include irregularly shaped pupils, delayed consensual light response, extrusion of vitreous, Seidel’s sign (fluorescein streaming of tears away from the puncture site).
  • Beware of intraocular hypertension (>21 mmHg) with high-grade traumatic hyphema which needs to be emergently addressed to prevent optic nerve atrophy and permanent vision loss.

  • Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70. doi: 10.1053/joms.2001.28284. PMID: 11732035.
  • Gharaibeh A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005431. doi: 10.1002/14651858.CD005431.pub2. Update in: Cochrane Database Syst Rev. 2013;12:CD005431. PMID: 21249670; PMCID: PMC3437611.


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