Surgery — Eye and ENT Emergencies, NMC MBBS licence examination syllabus (Nepal Medical Council).
Eye and ENT emergencies
A small number of conditions where hours of delay cost sight, hearing or an airway.
Most red eyes are conjunctivitis and most nosebleeds stop. But hidden among them are a handful of presentations that destroy vision within hours, and they are missed for a consistent reason: the dangerous ones look superficially like the trivial ones, and the examination that separates them is rarely performed.
That examination is not complicated. Test the visual acuity, ask about pain, and look at the pupil. Those three take a minute, need no equipment beyond a chart, and sort almost every red eye into the group that needs drops and the group that needs an ophthalmologist today.
🩺 Where this lives: Corneal blindness from an untreated ulcer is one of the commonest causes of avoidable vision loss in South Asia, and topical steroid given to an undiagnosed red eye is a recognised contributor. Steroid drops relieve inflammation impressively, so they feel like they are working — while in herpetic or fungal keratitis they accelerate destruction of the cornea. In settings where drops are available without prescription and where a red eye may be treated by whoever is nearest, this is a genuinely common route to a blind eye, and the rule against it is absolute for good reason.
💡 A note on numbers. This chapter gives no doses, no intraocular pressure values and no irrigation durations. Irrigation of a chemical injury targets a pH endpoint rather than a fixed number of minutes, pressure thresholds are context-dependent, and steroid dosing in giant cell arteritis follows national guidance. Croup, epiglottitis and inhaled foreign body in children are covered in the Breathless Child chapter, trauma airway in Trauma, and diabetic and hypertensive retinopathy in their own chapters.
The red eye
Three questions do the sorting. Is the vision affected? Is there pain? Is the pupil abnormal? Conjunctivitis is gritty and uncomfortable with normal vision and a normal pupil. Any reduction in acuity, any true pain rather than irritation, or any pupil abnormality moves the patient into the group needing same-day ophthalmology. And visual acuity is the vital sign of the eye — recording it takes a minute and is the single most useful thing in the notes.
THE RULE THAT MATTERS MOST
NEVER PRESCRIBE TOPICAL STEROID FOR AN UNDIAGNOSED RED EYE.
Why it is so tempting: steroid drops reduce redness and
discomfort quickly, so the patient improves and the
treatment appears to be working.
Why it is so dangerous: in HERPETIC (dendritic) keratitis
and in FUNGAL keratitis, steroid suppresses the immune
response while the organism continues to destroy the
cornea. The eye feels better while it is being lost. The
result is corneal scarring and permanent visual loss.
CONTACT LENS WEAR raises the possibility of microbial
keratitis and of acanthamoeba, and a red painful eye in a
contact lens wearer is referred rather than treated
empirically.
A CORNEAL ULCER may be visible as a white spot on the
cornea, and fluorescein staining shows an epithelial
defect. Any suspicion of ulceration warrants urgent
ophthalmology.
OTHER SIGHT-THREATENING CAUSES OF A RED EYE
ACUTE ANGLE CLOSURE GLAUCOMA — see below
ANTERIOR UVEITIS — pain, photophobia, blurred vision,
a small or irregular pupil; may accompany systemic
inflammatory disease
SCLERITIS — severe boring pain, often waking the patient
PENETRATING INJURY — sometimes with a deceptively quiet
eye
THE SAFE HABIT: record the acuity, examine the pupil, stain
with fluorescein where available, and refer rather than
reaching for drops when any of the three questions is
positive.
Acute angle closure glaucoma
💡 Exam angle: this is examined because it is systematically misdiagnosed. The patient presents with severe headache, vomiting and a red painful eye with haloes around lights — and because the headache and vomiting dominate, they are worked up for migraine, raised intracranial pressure or an abdominal cause while nobody examines the eye. The findings that clinch it are a hard eye and a mid-dilated, poorly reactive pupil. It is a same-day emergency because sight is lost in hours.
Sudden visual loss
THE ONE YOU CAN PREVENT
GIANT CELL ARTERITIS
In a patient over 50 with a new headache, consider it.
The supporting features:
SCALP TENDERNESS — combing the hair hurts
JAW CLAUDICATION — pain in the jaw on chewing, which is
the most specific symptom
Visual symptoms, transient or established
Systemic features: malaise, weight loss, proximal
aching
WHY IT MATTERS SO MUCH: visual loss is usually sudden,
painless and IRREVERSIBLE — and the second eye is at
risk within days if untreated.
THE RULE: treat on clinical suspicion and arrange
investigation afterwards. Do not wait for inflammatory
markers or biopsy before starting steroid — biopsy
remains informative for a period after treatment begins.
Doses follow national guidance.
THE OTHER CAUSES, SORTED BY PAIN
PAINLESS: retinal artery occlusion (sudden, profound,
like a curtain), retinal vein occlusion, retinal
detachment, vitreous haemorrhage.
PAINFUL: acute glaucoma, optic neuritis (pain on eye
movement, often in a younger patient), keratitis,
trauma.
RETINAL DETACHMENT announces itself: FLASHES and FLOATERS
followed by a curtain or shadow spreading across the
vision. It is a same-day referral, because outcome depends
on whether the macula is still attached.
In diabetic patients, sudden loss may be vitreous
haemorrhage — see the diabetes chapter.
Eye injury
Chemical injury is the only ophthalmic emergency where treatment precedes history-taking. Irrigate immediately with copious water or saline — before assessment, before referral, before anything. Alkali penetrates more deeply than acid and causes worse damage, so the irrigation continues well beyond the point at which things look settled, targeting a pH endpoint. In suspected penetrating injury, the opposite discipline applies: do not press on the eye, do not attempt to remove anything, shield it and refer.
ENT emergencies
💡 Exam angle: two items recur. Epistaxis first aid — sit the patient forward, not back, and pinch the soft part of the nose rather than the bony bridge; leaning back sends blood into the airway and stomach. And a button battery lodged in the nose or oesophagus is a genuine emergency requiring immediate removal, because it causes rapid caustic tissue destruction — a detail worth knowing precisely, since the child may simply present with drooling or nasal discharge.
Clinical reasoning: four presentations
🔍 Case 1 — steroid drops for a red eye
PresentationA man with a painful red eye and blurred vision is given steroid drops. His symptoms improve for two days, then the eye becomes intensely painful with a visible white spot on the cornea. He wears contact lenses.
ErrorTopical steroid to an undiagnosed red eye.
ReasoningPain with reduced vision indicated a serious red eye. Contact lens wear raises microbial keratitis, and steroid suppresses the response while the organism destroys the cornea — so the eye feels better while it is being lost.
AnswerStop the steroid and refer urgently. Test acuity and stain with fluorescein at first presentation, and never treat an undiagnosed red eye with steroid.
🔍 Case 2 — headache and vomiting
PresentationA 62-year-old presents with severe headache and vomiting. She mentions haloes around lights. She is investigated for raised intracranial pressure. Nobody examines her eyes; one is red and feels hard.
Missed diagnosisAcute angle closure glaucoma.
ReasoningHeadache and vomiting dominate the presentation, so the eye is overlooked. Haloes, a red hard eye and a mid-dilated poorly reactive pupil are characteristic, and sight is lost within hours.
AnswerSame-day ophthalmology referral. Examine the eyes in any patient with headache and vomiting, and avoid dilating drops where angle closure is possible.
🔍 Case 3 — jaw pain when chewing
PresentationA 71-year-old has a new headache with scalp tenderness and aching in the jaw when eating. She had brief blurring of vision yesterday. Inflammatory markers are sent and treatment is deferred until they return the next day.
DangerWaiting.
ReasoningNew headache over 50 with scalp tenderness and jaw claudication suggests giant cell arteritis. Visual loss is sudden, painless and irreversible, and the second eye is at risk within days.
AnswerStart treatment immediately on clinical suspicion per national guidance, then arrange investigation and biopsy — which remains informative for a period after treatment begins.
🔍 Case 4 — lime in the eye
PresentationA construction worker arrives with cement powder in both eyes. Staff begin taking a history and arrange an ophthalmology referral before starting any treatment.
ErrorAnything before irrigation.
ReasoningCement is alkaline, and alkali penetrates deeply and continues damaging tissue while present. This is the one ophthalmic situation where treatment precedes assessment entirely.
AnswerIrrigate immediately with copious water or saline, continuing well beyond apparent settling and targeting a pH endpoint, then assess and refer.
Commonly confused
Confusion
The distinction
Why it matters
Conjunctivitis vs serious red eye
Vision, pain and the pupil
Three questions sort almost all of them.
Steroid drops vs referral
Never steroid to an undiagnosed red eye
It accelerates corneal destruction.
Improving vs improving safely
Steroid masks while damage continues
The eye feels better while being lost.
Headache and vomiting vs the eye
Examine the eyes anyway
Angle closure is missed this way.
Awaiting tests vs treating GCA
Treat on suspicion
Visual loss is irreversible.
Painless vs painful visual loss
It splits the differential
Different urgency and different causes.
History vs irrigation
Chemical injury is irrigated first
The only treatment preceding assessment.
Leaning back vs forward in epistaxis
Forward, pinching the soft part
Leaning back sends blood to the airway.
Rapid revision
MUST-KNOW FACTS
1. THE RED EYE: is vision affected, is there pain, is the pupil abnormal?
2. Any YES means same-day ophthalmology, not drops.
3. RECORD VISUAL ACUITY — it is the vital sign of the eye.
4. NEVER GIVE TOPICAL STEROID TO AN UNDIAGNOSED RED EYE.
5. It accelerates HERPETIC and FUNGAL keratitis and can cost the eye.
6. Steroid makes the eye feel better while it is being destroyed.
7. CONTACT LENS WEAR raises microbial keratitis — refer, do not treat.
8. A white spot on the cornea suggests an ULCER — urgent referral.
9. ACUTE ANGLE CLOSURE: severe pain, red eye, HALOES, reduced vision.
10. A HARD eye with a MID-DILATED, poorly reactive pupil.
11. Often with headache and VOMITING — and frequently misdiagnosed.
12. Examine the eyes in any patient with headache and vomiting.
13. Avoid dilating drops if angle closure is suspected.
14. Sight is lost in HOURS — same-day referral.
15. GIANT CELL ARTERITIS: over 50, new headache, scalp tenderness.
16. JAW CLAUDICATION is the most specific symptom.
17. Visual loss is sudden, painless and IRREVERSIBLE.
18. The SECOND EYE is at risk within days.
19. TREAT ON SUSPICION — do not wait for markers or biopsy.
20. Biopsy remains informative for a period after treatment starts.
21. PAINLESS loss: artery or vein occlusion, detachment, vitreous bleed.
22. PAINFUL loss: glaucoma, optic neuritis, keratitis, trauma.
23. FLASHES and FLOATERS with a curtain = RETINAL DETACHMENT.
24. CHEMICAL INJURY: IRRIGATE IMMEDIATELY, before anything else.
25. ALKALI penetrates deeply and is worse than acid.
26. Irrigate to a pH endpoint, not for a fixed time.
27. PENETRATING INJURY: do NOT press or remove anything — SHIELD and refer.
28. Hammering or grinding suggests an intraocular foreign body.
29. EPISTAXIS: sit FORWARD and pinch the SOFT part of the nose.
30. Leaning back sends blood into the airway and stomach.
31. STRIDOR in an adult is a closing airway — senior help early.
32. Deep neck infection: trismus, drooling, neck swelling.
33. Sudden sensorineural hearing loss needs urgent referral.
34. A BUTTON BATTERY in the nose or oesophagus is an emergency.
💡 Exam angle: three rules carry this chapter — test the acuity, never give steroid to an undiagnosed red eye, and irrigate a chemical injury before doing anything else. Each is absolute, and each is the answer to a question stem offering something more sophisticated.
Syllabus points
The three questions that sort a red eye
Visual acuity as the vital sign of the eye
Why steroid must never be given blindly
Contact lenses and microbial keratitis
Acute angle closure glaucoma
Why it is mistaken for migraine
Giant cell arteritis and jaw claudication
Treating on suspicion
Painless versus painful visual loss
Retinal detachment
Chemical injury and immediate irrigation
Suspected penetrating injury
Epistaxis first aid
Stridor, deep neck infection and button batteries
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