18. Red and Painful Eye Flashcards
DDX of traumatic causes of red and painful eye
caustic fluids
solid material
low or high velocity blunt force: retrobulbar hematoma; abscess; emphysema with Oribital compartment syndrome and suspision for open globe
Describe the external appearance/parts of the eye
Cilia/eyelashes
inferior and superior punctum (lower and upper parts of eye maarking distinction skin and eyeball)
inner canthus s outer canthus - part where two puntum meet
caruncle (inner part of inner canthus)
sclera (white)
Limbus - corneoscleral junction
cornea overlying the iris –> iris sphinter inside the collarette *(part where pupil and iris crypt/color part meet)
Describe the pathway of the internal eye from the cornea to the optic nerve
- cornea
2.continuous with the limbus (canal of schlemm sits at this junction) - between the lens and cornea have anterior chamber and iris on either side of lens
- inside cornea and beside lens: posterior chamber and ciliary body)
- inner layer from limbus is pars plana, then retina
- fovea at the back near optic nerve
DDX nontraumatic pain and red eye - 2 main categories
inflamm/infx MAIN
Key PE tests for a red and painful eye
VVEEPP ++
Visual acuity (best possible using correction)
Visual fields (tested by confrontation)
External examination: Globe position in orbit, Conjugate gaze, Periorbital soft tissues, bones, and sensation
Extraocular muscle movement
Pupillary evaluation (absolute and relative)
Pressure determination (tonometry)
+ Slit-lamp examination
+ Funduscopic examination
How to characterize a red and painful eye history?
complaint: pain type - itch/burn/dull/sharp/diffuse/local
sudden/slow ojnset
FB sensation (high sn corneal abrasion)
Where is the redness
Other sx - tearing/blink/discharge/discomfort/sn to light
7 red flag findings for a serious dx in pt with red or painful eye
Severe ocular pain
Persistently blurred vision
Exophthalmos (proptosis)
Reduced ocular light reflection
Corneal epithelial defect or opacity
Limbal injection (also known as ciliary flush)
Pupil unreactive to a direct light stimulus
Key past ocular hx questions (box 18.2)
- Do you wear contact lenses? If so, what type, how are they cleaned, and how old are the lenses? How often is the lens solution changed?
- Do you wear glasses? If so, when was your last evaluation for your glasses prescription? Do you have any changes in your vision?
- Have you had previous eye injury or surgery?
- What is your past medical history? Do you have any systemic diseases that
may affect the eye? Do you have a weakened immune system? - What medications do you take?
- Do you have any allergies?
How far should you stand for a snellen chart vs rosenbaum
20ft/6m
or
14inches
Medical causes of exopthalmus
orbital cellulits
intraorbitsal/lacrimal tumor
hyperthyroidism
orbital emphysema from FB
What are signs of orbital compartment syndrome?
exopthalmos
iop incr
rapd
Why do we worry about orbital compartment syndrome?
globe is pushed forward, stretched opptic nerve and retinal a and increasing iop –> microvascular ischemia is sight threatneing
What findings on the conjunctiva indicate a viral cause?
punctate follices on conjunctiva on one or both lids - hypertrophy of lymphoid tissue in
Bruch’s glands
*though chlamydia can cause it too!
Red eye in a neonate: absence of corneal abrasion, when to consider neisseria gonorr vs chlamydia
2-5d after birth
5-12d after birth
Dipopia on extreme gaze in EOM may indicate which?
entrapment of EOM within fracture site (can also just be edema or hemorrhage and is functional rather than true entrapment)
What % of gen pop has anisocoria?
10%
Anterior chambers: what two things can fill here?
blood (hyphema)
pus (hypopyon)
N IOP
10-20mmHg
Key hx in acute angle closure glaucoma
pain sudden onset low light condition
iop incr–> frontal headache, nausea/emesis
Pathophys of acute angle closure glaucoma
low light acute onset - pupillar dilatation through contraction and thickening of iris peripherally –> iris immoble and irregular, pupil commonly fixed 5-6mm in diameter
does not constrict, resulting in photophobia and accommodation can be affected
later on can get limbal injection
IOP >20 vs >30
> 20 but <30 needs optho
30 needs urgent tx
What pathophys can cause an RAPD?
vitreous hemorrhage
retinal ischemia/detachment
pre-chiasmal optic nerve lesions
What is a slit lamp for?
anterior eye structures: magnified binocular view of conjunctivae and anterior globe –> cornea, aqureous humor, lens
Walk through an approach for slit lamp examination
- Lids and lashes inspected for blepharitis, lid abscess (i.e., hordeolum) and internal or external pointing, and dacryocystitis.
- Conjunctiva and sclera inspected for punctures, lacerations, and inflam- matory patterns.
- Cornea (with fluorescein in some cases) evaluated for abrasions, ulcers, edema, foreign bodies, or other abnormalities.
- Anterior chamber evaluated for the presence of cells (e.g., red and white blood cells) and “flare” (diffuse haziness related to cells and proteins sus- pended in aqueous humor), representing deep inflammation. Hyphema from surgery or trauma, hypopyon, or foreign bodies may also be noted.
- Iris inspected for tears or spiraling muscle fibers noted in acute angle- closure glaucoma.
- Lens examined for position, general clarity, opacities, and foreign bodies.
How does fluorescein work?
ID cornea defect - fluorescein not taken up by intact corneal epithelium
Seidel’s test - for what and how do you use it?
corneal perforation
anterior chamber leakage
2% fluorescein
slit lamp, cobalt blue setting
bright green leakage = + test
What testis used to identify posterior eye structures?
fundoscopy
When to get imaging (ie ct, u/s) of the eye
penetrating wound/suspected trauma- ct
FB suspected, dislocation, retinal detachment, globe rupture, retrobulbar hematoma, vitreous hemorrhage - u/s
Name 7 causes of inability to see red reflex
- corneal opacification due to edema (injury, infection)
- hyphema/hypopyon
- miotic pupil
- cataract of lens
- blood in vitreous or posterior eye wall
- Retinal detachment
- intraocular mass like retinoblastoma
Caustic injuries to the eye: immediate first steps
irrigation ++++ until ph is neutral
try 30mins 1-3L fluid: LR
Caustic injuries to the eye: alkalotic injury name
liquefaction necrosis (just keeps goingthrough laters)
Caustic injuries to the eye: acidic injury name
coagulation necrosis (limits penetration depth)
Name 3 critical diagnosis of a red and painful eye
caustic injury
retrobular hematoma
orbital compartment syndrome (the above can cause this)
Name 5 emergent diagnosis of the eye
ketatitis
anterior uveitis
scleritis
endopthalmitis
penetrating trauma and injured globe
Red flag questions in red and painful eye - name 4
- any fb?
- recent blunt or penetrating trauma
- sudden loss of all or part of vision
- double vision
Blunt or penetrating injury with exopthalmos or hemorrhage ddx - 4
Critical
2. Orbital compartment syndrome
Emergent
3. Penetrating injury of the globe
Urgent
4. Hyphema
Non-urgent
5. Subconjunctival hemorrhage
Blunt or penetrating injury withOUT exopthalmos or hemorrhage ddx - 4
Emergent
6. Corneal perforation
7. Ruptured globe
Urgent
8. Corneal abrasion with or without FB
Non-urgent
9. Traumatic mydriasis
Swelling or erythema of an external structure with MORE than isolated lid involvement?
Critical
2. Orbital compartment syndrome
Emergent
10. Inflammatory pseudotumor
11. Orbital cellulitis
Urgent
12. Periorbital cellulitis or erysipelas
13. Dacryocystitis and dacryadenitis
14. Orbital tumor
Swelling or erythema of an external structure withOUT more than isolated lid involvement?
Urgent
15. Hordeolum (stye)
Non-urgent
16. Blepharitis 17. Chalazion
DDX of severe pain, FB sensation or limbal injection? name 7
Critical
18. Narrow angle glaucoma
Emergent
4. Hyphema
19. Keratitis
20. Scleritis
21. Anterior uveitis and hypopyon
22. Endophthalmitis
Urgent
23. Keratoconjunctivitis
24. Episcleritis
Infection of bulbar BUT not limbal conjunctiva: ddx
Critical
18. Narrow angle glaucoma
Emergent
4. Hyphema
19. Keratitis
20. Scleritis
21. Anterior uveitis and hypopyon 22. Endophthalmitis
Urgent
23. Keratoconjunctivitis 24. Episcleritis
How to treat corneal ulcerations secondary to overuse contact lenses
proph abx and avoidance lenses 72h
Scleritis secondary diseases- list 6
RA
GPA
lyme
syphilis
tb
ctd
gout
Endopthalmitis - what pt pop to consider this in?
immunocomp
Management of hyphema
HOB 30
systemic analgesia
antiemetics
optho
stop plt meds
shield over eye during sleep, not day
which hyphemas need inpt tx?
> 50% hyphema
incr iop
sickle cell disease or trait
hx coagulopathy
difficulty adhereing to tx plan outpt
Best way to irrigate solids vs acids vs alkali
solids - remove and dry swab out first
acids: min 2L for 20 min/alkali: 4L for 4min
When do youy use a lateral canthotomy and cantholysis in the ED?
retrobulbar hematoma
Corneal abrasion drops:
abx polymyxin-B/TMP solution 1 dropq3h when awake, erythromycin when asleep
Inflammatory pseudotumor: Nonspecific idiopathic retrobulbar inflammation with eyelid swelling, palpebral injection of conjunctiva, chemosis, proptosis, blurred vision, painful or limited ocular mobility, binocular diplopia, edema of optic disk, or venous engorgement of retina
w/u
measure iop
look for infection/dm/vasculitis with cbc/bmp/ua and crp/esr
ct if needed
Orbital vs periorbital cellulitis? differences
orbital: fever, ill appear, blurry vision, proptosis, painful.limited ocular mobility, binocular diplopia, edema of optic disk, venous engorgement of retina
ABX for orbital cellulitis
vanco
ceftr and flagyl
What is dacrocytitis?
Eye tearing and inflammation of lower eyelid inferior to lacrimal punctum finding redness and tenderness over nasal aspect of lower lid and adjacent periorbital skin
Name 6 medications to treat glaucoma
- DEcr production of aqueous humor
Timolol 0.5%1 drop
apraclonididine 1% 1 drop
Dorzolamide 2% 1 drop or if sickle cell disease/trat: methazolamide 50mg PO - Decr inflamm: prednisolone 1% 1 drop q14 min x4
- Constrict pupil: pilocarpine 1-2% 1 drop after IOP <50, then repeat 15min later
- Consider incr osmotic gradient - mannitol 2g/kg IV
What eye conditions other than glaucoma are treated with similar meds?
orbital compartment syndrome to decr IP pre decompression
hyphema
What conditions can use ceftr, vanco, flagyl to tx?
retobular abscess
orbital cellulitis
preorbital “
dacrocystitis
Tx keratitis
topical fluoroquinoline
Keratitis herpetic infection tx - how will you know it is more likely caused by herpes?
dendritic defects in cornea with fluorscein under cobalt blue light
acylovir 5% ointment or trifluridine 1% solution
Scleritis tx
decr inflamm PO nsaid
anterior uveitis and hypopyon tx
r/o gluacoma with iop meausrement
prescribe in ED if >20
otheriwse cna dilate pupil with 2 drops cyclopentolate 1%
Endopathlmatitis tx
vanco and ceftrazidime
or if CI: cipro or levoflox
what is an . Inflamed pinguecula
Inflammation of soft yellow patches in temporal and nasal edges of limbal margin
can tx with ketorloac drops
what is an inflamed pterygium?
Inflammation of firmer white nodules extending from limbal conjunctiva onto cornea
? no tx per Rosens?
epislceritis tx
artifical tears
Chlamydial conjunctivitis abx tx
azithro
Allergic conjunctivitis tx
Decrease irritation with naphazoline drops or consider ophthalmic antihistamine
A patient who normally wears contact lenses is diagnosed with bac- terial conjunctivitis. Which of the following is the preferred treat- ment in this patient?
a. Bacitracin
b. Chloramphenicol c. Erythromycin
d. Moxifloxacin
d - tx pseudomonas
Which of the following results from inflammation of a meibomian
gland?
a. Blepharitis
b. Chalazion
c. Dacryocystitis d. Hordeolum
b
A 15-year-old boy presents to the emergency department (ED) after
having been shot in the face with a BB gun. He has a solitary pen- etrating wound just inferior to his left eye. His visual acuity in the left eye is limited to light perception, but he reports having normal vision prior to the injury. He has significant proptosis of his left eye, and his fundus is clearly seen with direct ophthalmoscopy. Intra- ocular pressure (IOP) of the affected eye is 50 mm Hg. His mental status is normal. What is the most appropriate next step in the man- agement of this patient?
a. CT scan of the head and face
b. ED observation with repeated neurologic examinations c. Lateral canthotomy and inferior cantholysis
d. Plain radiography of the face
c
A neonate presents 7 days after birth with a unilateral red eye. Fur- ther examination reveals inflamed conjunctiva, purulent discharge and negative uptake on fluorescein examination. The child was born full term after a pregnancy complicated by poor prenatal care. Which of the following diagnoses is most likely in this patient?
a. Chemicalconjunctivitis b. Chlamydia trachomatis c. Cornealabrasion
d. Neisseria gonorrhoeae
b
