Red Eye Flashcards
What is the 5th vital sign of the eye?
What are three exceptions when you dont have to check it?
Visual acuity
Oopen globe (rigid shield), caustic injury (start irrigating), sudden visual loss (getting them to ct to rule out a stroke)
Outline relevent anatomy of the eye (Rosen’s diagrams)
What are 3 conditions that are vision threatening that will not present with pain or redness?
Retinal detachment
CRVO
CRAO
(diagnosed with fundoscopy)
Why do you get a cherry red spot with CRAO?
The perfused choroid shows through the inner fovea
What are pivotal findings much more likely to be something serious?
Severe occular pain
Exopthalamous
Persistently blurred vision
Corneal epithelial defect or opacity
Reduced occular light reflection
Ciliary flush
Pupil unreactive to light
Think overall bad, anterior chamber penetrating injury bad, and then interior structures bad
What are 6 key questions to ask on your optho history?
- Do you wear contacts
- Do you wear glasses
- Any previous eye injury or surgery
- Past medical history
- Medications
- Allergies
First three help to establish vision at baseline, next three basic HPI
Link the following with their common differential:
FB sensation
Itching
Burning
Sharp pain
Dull pain
Intense Pain
FB sensation - corneal problem, keratitis, abrasion, ulcer
Itching - irritation/ infection, dry eye, conjunctivits, blepharitis
Burning - Superficial problems, pinguecula, pteryium, episcleritis
Sharp pain - anterior eye uvea or cornea
Dull pain - headache/ generalized think increased IOP with glaucoma, AACG, reffered pain sinusitis or migraine
Intense Pain - obrital compartment syndrome, retrobulbar hematoma
Discharge - conjunctivitis - allergic, viral, bacterial, Blepharitis, dacryocystitis, and canaliculitis (infection of two little tubes that drain into tear duct)
What is most common diagnosis with red eye that is completely asymptomatic (looks worse than is)
Spontaneous subconjunctival hemmorhage
Usually after straining, coughing or no trigger
What is the evidence for trying to tell if viral or bacterial conjunctivitis? Is this clinically relevent?
No redness at 20 feet
No AM eyelid matting
Presentation in summer
Less likely bacterial. Even if it was bacterial if you are immunocompetent, do not wear contact lenses, and dont have a trauamtic injury no need for drops anyways
What are 8 components of the eye exam?
VVEEPP
Visual acuity
Visual field
External exam
Extraoccular movements
Pupils
Pressure
+slit lamp and fundoscopy
Slit lamp for any trauma, fb or altered vision
Outline your approach for testing visual acuity
Ideally Snellen chart read at 6m, one eye at a time, can use pinhole for refractory errors
For kids can do an Allen chart (shapes)
If they cant do letters do a qualitiative test i.e. read at this distance
If they are really struggling you can do in order
Can they count fingers
Can they see hand motion
Can they see light
What is a scotoma?
Medical term for blind spot
Usually a retina problem
think glaucoma if crescent shaped
think brain if hemi or quandrant loss
Most common cause of endopthalamous in ED?
Pseduo - other eye is actually just protuding
What are punctate follicles in eyelid? What do they represent?
Punctate “follicles” are hypertrophy of lymphoid tissue in Brunch glands along the conjunctival surface of one or both lower lids. Relatively specific for viral etiology
Alternative diagnosis is trachoma, a form of chronic keratitis conjucntivitis with chalymdia that also has the same findings
What are the most common causes of irregular shaped pupils?
Blunt or penetrating trauma
Previous surgery (iridotomy or cataract extraction)
Synechiae from prior iritis or inflammatory changes
Drugs
Toxins
if just one is constricting with direct light worry about bad optho stuff liek globe problem, afferent nerve problem, ciliary muscle problem, uveitis ect
What is normal for IOP? What are relevent cut offs to know?
10-20 is normal
>20 reasonable to be seen by optho
>30 requires rapid treatment
Someone explain wtf “cupping” of the optic disc is to me please
Cupping is a clinical sign of increased IOP seen on fundoscopy. As IOP increases it pushes back on the optic nerve creating a “cup” shape. We see this as the transition from a small flat well rounded circle to a wide high contrast circle.
Thank you Frank
What should you do if you see a baby with red eyes? What are some relevent differentials?
Red eyes in a baby or neonate is always abnormal
Corneal abrasions - inconsolable infant
Hepres Keratitis - birth canal or caregivers fingers
Conjunctivtis - first few days think gonorrhea, 1-2 weeks think chlamydia
6 components of you slit lamp exam
Lids and lashs
Conjunctiva and scelra
Cornea
Anterior chamber
Iris
Lens
Outside and peripheral to inside and central
What does corneal edema look like on a slit lamp exam? Why might this be tricky if you have a junior trainee? What is one diagnosis this is relevent for?
Increased interstitial water creates a whitish cladding of the normally clear tissue at base or adjacent to lesion
best seen without the fluroscein staining
corneal ulcers can have this around them indicating concomitant keratitis
When might an open globe be really hard to diagnose
Projectile to the back of the eye
Lean on imaging (CT - cant MRI if something is in there)
Alternatively very small FB - might only see small entrance wound of scleral bruising. Trick is to have a high index of suspicion if any projectile mechanism.
5 occular diagnoses you might be able to make with US?
Retinal detchament
Vitreous hemmorage
Vitreous detachment
Open globe (hopefully not)
Intraoccular FB
6 reasons you cant see a red reflex or optic fundus?
Which burns need to be seen by optho?
Full thickness
How do you treat corneal abrasions casued by contact lenses
Antibiotics (vigamox or moxifloxacin)
No lenses for 72 hours then see optho
List 3 causes of uveitis?
List some causes of scleritis
Uvetitis - JRA, sarcoidosis, ank spond, IBD
Scleritis - HIV, syphillis, TB
Scleritis can be anterior or posterior
Which patients with hyphema need to be admitted to hospital?
> 50% of visual field
Increased IOP
Sickle cell
Coagulopathy
Cant adhere to treatment as outpatient
Outline minimums for irrigation with causic exposure
Acid - 2L or 20 minutes
Alkali - 4L or 40 minutes
Asymptomatic with injury >1 hour ago - nothing
Target pH of 7
How does one get retrobulbar emphysema?
Forceful sneeze (great) - relevent because antibiotics need to cover sinus flora
Occasionaly can be spontaneous
What is an inflammatory pseduotumor? How does it present? How do you work it up? How do you treat?
Non-specific idiopathic retrobulbar inflammation
Can present with swollen everything - eyelids, injection of conjunctiva, chemosis, proptosis, painful EOM, and then if really bad signs of increased IOP like edema of optic disc or venous engorgement of retina
Measure IOP. Needs inflammatory workup CRP, CBC, UA, BMP, CT or orbits see what is back there.
Optho
Might get high dose steroids
Distinguishign features from orbital vs pre-septal cellulitis according to the red eye chapter
Fever
Ill appearance
Blurred vision
Proptosis
Painful or limited EOM
Binocular diplopia (remember binocular is a tracking/ allign of visual gaze problem)
englargement of optic disc, venous engorement of retina
What is an inflammatory condition that can block up a tear duct (aka inferior punctum)?
Lupus. Of course.
If you think its blocked warm comrpesses, amox/clav, massage it QID, pain meds
3 instructions you give to bhlepharitis?
Artifical tears (inflamamtion is irritating)
Warm compresses
Rub eye lid margins with mild shampee on washcloth twice a day
Topical medication you give instead of diamox if someone has sickle cell and traumatic hypheme increased IOP?
Cant get diamox
methazolamide PO
What is SPK?
Superficial punctate keratitis - see stipling of the cornea, often lower 2/3 if due to light
How do you treat herpetic infection?
How is uveitis treated?
Endopthalmitis?
HSV - acyclovir ointment PO - consult with optho
Varicella zoster, CMV not usually given anything if immunocompetent
Often topical steroids in consult with optho
Ceftazidime/ vanco
What are naphazoline drops? Rosens mentions them for allergies, conjunctivitis
Naphazoline is a decongestant used to relieve redness, puffiness, and itchy/watering eyes due to colds, allergies, or eye irritations (smog, swimming, or wearing contact lenses). It is known as a sympathomimetic (alpha receptor agonist) that works in the eye to decrease congestion.
How do you actually see flare?
