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
