Ophthalmic emergencies are time-critical situations where delays in recognition or management can lead to permanent vision loss [1]. For resident doctors and medical students, identifying these red flags can be daunting, especially given the complexity of the eye and its many potential pathologies.
Unfortunately, despite the critical importance of ophthalmic emergencies, medical education often falls short in adequately preparing students. A 2025 UK-based survey revealed that ophthalmology education is frequently rated poorly, with many students reporting insufficient exposure to clinical ophthalmology during their training [2]. This lack of exposure is concerning, as early recognition and management of eye emergencies are vital for patient outcomes [2]. Below are the top five most important ophthalmology emergency presentations.
1. Sudden, painless loss of vision
May indicate central retinal artery occlusion (CRAO), retinal detachment, vitreous haemorrhage, arteritic or non-arteritic anterior ischaemic optic neuropathy (AION) [3].
- Significance: Any delay in management can result in irreversible retinal damage, leading to permanent vision loss.
- Key diagnostic features: Presence of a relative afferent pupillary defect in optic neuropathy, a cherry-red spot on fundoscopy in central retinal artery occlusion, a sudden onset of dense floaters or haze in vitreous haemorrhage, or a ‘curtain’ descending over the visual field in retinal detachment.
- Recommended action: Treat CRAO as a stroke, refer suspected retinal detachment urgently, and if arteritic AION suspected, check inflammatory markers, refer to ophthalmology for fundus evaluation and start steroids [4].
2. Painful red eye with visual loss
A painful red eye with decreased vision is a serious ocular emergency that warrants immediate evaluation. Common causes include acute angle-closure glaucoma, microbial keratitis, scleritis and uveitis [5].
- Significance: These conditions can progress rapidly, leading to irreversible damage to ocular structures and permanent vision loss if not promptly managed.
- Key diagnostic features: Presence of ciliary flush, photophobia, corneal opacity or infiltrate, fixed mid-dilated pupil, and elevated intraocular pressure.
- Recommended action: Immediate referral; avoid topical steroids unless advised by ophthalmology [5].
3. Ocular trauma
Penetrating or blunt trauma can cause rupture of the globe, retinal detachment or endophthalmitis (infection inside the eye).
- Significance: Trauma can result in vision-threatening structural damage or infection [6].
- Key diagnostic features: History of trauma, irregular pupil, extrusion of ocular contents, decreased vision.
- Recommended action: Protect the eye (rigid shield, no pressure), nil by mouth, systemic antibiotics and urgent ophthalmology review [6].
4. Diplopia with ptosis or pupil involvement
Double vision with ptosis or pupil dilation may indicate a third cranial nerve palsy [7]. This presentation can arise from several causes, including compressive lesions, microvascular ischaemia (commonly due to diabetes or hypertension), trauma, neoplasm or raised intracranial pressure. The oculomotor nerve controls most extraocular muscles (superior, medial and inferior recti, and inferior oblique), the levator palpebrae superioris (responsible for eyelid elevation), and carries parasympathetic fibres that mediate pupillary constriction and lens accommodation.
- Significance: Untreated intracranial aneurysms can be fatal.
- Key diagnostic features: Eye positioned ‘down and out’, ptosis, dilated or sluggish pupil.
- Recommended action: Urgent neuroimaging with contrast and neurosurgery consultation if a vascular lesion is suspected [7].
5. Flashes and floaters
Flashes are brief, bright, lightning-like streaks or arcs of light perceived in the peripheral visual field. Patients often describe them as ‘flashes of light’, ‘sparkles’ or ‘camera flashes’, especially in low lighting or with eye movement. Floaters are small, dark, semi-transparent shapes moving across the visual field. They may resemble spots, threads, cobwebs or ring-like structures that drift with eye movement but seem to ‘lag’ slightly behind. These symptoms often indicate posterior vitreous detachment, retinal tears or detachment [8].
- Significance: Timely surgical intervention preserves vision.
- Key diagnostic features: Sudden increase in floaters, photopsia (flashes), peripheral visual field defects (‘curtain’).
- Recommended action: Same-day ophthalmology referral and advise the patient to avoid driving [8].
Conclusion
The importance of early recognition and management of ophthalmic emergencies cannot be overstated. The presentations outlined above – from sudden painless loss of vision to ocular trauma and retinal detachment – represent the core red-flag presentations that every frontline clinician must be able to identify. Timely intervention can preserve sight and prevent life-threatening complications, while delays can result in permanent blindness.
To improve outcomes, there must be a greater emphasis on ophthalmology education within the medical curriculum, incorporating simulation training, case-based learning, and early clinical exposure. Improving diagnostic confidence among junior doctors ensures that these critical presentations are recognised promptly, managed appropriately and referred without delay. Ultimately, vigilance, awareness and rapid referral remain the cornerstones of effective management in ophthalmic emergencies.
References
1. Dag Y, Aydın S, Kumantas E. The profile of patients attending the general emergency department with ocular complaints within the last year: is it a true ocular emergency? BMC Ophthalmol 2024;24(1):330.
2. Elhariry M, Badawy A, Mustafa A, et al. Assessing medical students’ ophthalmology exposure and its role in their speciality choices: a national survey. Cureus 2025;17(8):e90814.
3. Brady CJ. Sudden Vision Loss. MSD Manual Consumer Version 2025:
https://www.msdmanuals.com/home/
eye-disorders/symptoms-of-eye-disorders/
sudden-vision-loss
4. https://cks.nice.org.uk/topics/retinal-detachment/
5. https://cks.nice.org.uk/topics/red-eye/
management/management-of-red-eye/
6. https://patient.info/doctor/ophthalmology/
eye-injuries?utm_source=gpoptin
7. Islami RH, Agustini L, Suhartono G. Diplopia as a sign of third nerve palsy due to intracranial aneurysm: a case report. Pan Afr Med J 2024;48:104.
8. Bergstrom R, Czyz CN. Vitreous floaters. StatPearls. Treasure Island (FL): StatPearls Publishing; 2025.
[All links last accessed December 2025]
Declaration of competing interests: None declared.
