Red Eye Flashcards
Hx w/ Red Eye
Symptoms: blurred vision? Pain? (irritation/foreign body sensation vs. deep boring pain) Eyelid/eye swelling Tearing Mattering/discharge Photophobia Flashes Floaters
Red Eye Past Ocular Hx
Contact lens use
Trauma
Surgery
PE w/ Red Eye
Vital signs of eye
Eyelids/lashes, Conjunctiva/sclera, cornea, anterior chamber, iris, lens
Hordeolum/Chalazion (stye)
Inflammatory nodules in eyelid caused by blockage of sebaceous gland +/- infection
Signs/Sx: Focal lid swelling/redness/pain
Treatment: warm compress +/- topical antibiotic drops/ointment
Typically self-limited
When to refer? lesions present >1 mo
Blepharitis
Chronic inflammation of eyelid margin often caused by staph
Signs/Sx: Burning, irritation, thickened/hyperemic lid margin & crusting
Treatment: warm compress, scub eyelids w/ baby shampoo, artificial tears PRN
When bad, can get ulcers on cornea
Demodex
mites that live on eyelashes & can cause inflammation of eyelid margin
Treat w/ tea tree oil
Contact dermatitis
DELAYED hypersensitivey to agents that come into contact w/ skin (e.g. eye drops, cosmetics)
Signs/Sx: Itching, eyelid redness, swelling
Tx: Stop the offending agent
Herpez Zoster Ophthalmicus
Reactivation of varicella zoster virus in V1 dermatomal distribution
Signs/Sx: Painful, vesicular rash that respects midline
Tx: Oral acyclovir or Valacyclovir
Refer when: Evaluation of eye involvement –> Decreased in vision or Hutchinson’s sign
Hutchinson’s sign
Rash on tip of nose w/ herpes zoster ophthalmicus
Nasociliary involvement of V1 –> eye involvement
Preseptal cellulitis
Infection of eyelids & soft tissue ANTERIOR to orbital septum (May be secondary to skin infection, trauma, sinus infection)
Signs/Sx: Eyelid edema & erythema, NORMAL motility, pupils & visual acuity
If suspect orbital cellulitis? CT w/ contrast to look for abscess
Tx: systemic abx; hospital admission if severe or young patient
Orbital cellulitis
Infection POSTERIOR to orbital septum (may begin as preseptal cellulitis, sinusitis, tooth abscess)
MEDICAL EMERGENCY
Signs/Sx: lid edema & erythema, IMPAIRED ocular motility, proptosis, chemosis, DECREASED vision, RAPD
Tx: Hospital admission, Emergent ophtho consult, blood cultures, CT orbits, IV abx +/- abscess drainage
COMPLICATIONS: Optic nerve damage (from compression), Meningitis (2%), Cavernous sinus thrombosis
Dacrocystitis
Infected lacrimal sac
Most common in infants (delayed opening of nasolacrimal passage)
In adults, occurs when nasal passage blocked by trauma, neoplasm or inflammation
Signs/Sx: Tearing, discharge, medial lower lid swelling/redness
Tx: NLD massage in infants +/- abx, abx in adults
Refer when: No improvement or recurrent
Conjunctivitis
Non-specific term for conjunctiva inflammation
Causes: bacterial, viral (most common), allergic (does it itch?), autoimmune
Hx to help w/ etiology: sick contacts? has it spread? tearing? discharge? itchiness? vision changes? contact use?
Bacterial conjunctivitis
Signs/sx: Chemosis, redness, prurulence
Tx: Swab/culture, broad abx drops (polytrim, ocuflox, ciloxan). Delay may result in vision loss
Gonococcal infection? Systemic abx & possible hospitalization (consider sexual assault when in kids)
Refer when? No improvement OR immediately if its gonococcal
Viral conjunctivitis
Signs/sx: watery mucoid discharge, often spreads to other eye, URI, enlarged lymph nodes
Commonly adenovirus, enterovirus
Self-limited (should resolve in 7-10 days)
Tx: Supportive (ATs, cool compresses)
HIGHLY CONTAGIOUS Quarantine until discharge resolves; frequent hand washing; wash clothes, pillow cases, etc.
Allergic conjunctivitis
Seasonal or perennial
Signs/sx: Itching, chemosis, tearing, papilla bumps on eyelid margin
Tx: topical antihistamines or oral agent if respiratory component, OTC eye drops
Autoimmune conjunctivitis
Associated w/ systemic disorders such as Grave’s, vasculitides, sarcoidosis
Signs/sx: diffuse redness, orbitopathy
Tx: treat autoimmune disease & sx in meantime
Subconjunctival Hemorrhage (Hyposphagma)
Dramatic but benign
Often result of sneezing, nose blowing, eye rubbing
Associated w/ use of antiplatelet agents & anticoag
Signs/Sx: Mild foreign body sensation, NO VISION CHANGES
If recurrent –> Consider eval for blood dyscrasias, HTN.
No blood thinners? Get CBC platelet count
Scleritis & Episcleritis
Autoimmune inflammation of episclera or sclera
Episcleritis Signs/sx: Focal tenderness, redness, swelling, mild pain
Scleritis Signs/sx: Deep aching pain, redness, +/- scleral thinning
Scleritis usually associated w/ systemic connective tissue disease (i.e. lupus) VISION THREATENING
Tx: oral/topical NSAIDS for episcleritis, systemic immunosuppressants for scleritis
Difficult to distinguish on exam
Refer in 1-2 days for eval
Pinguecula & Pterygia
Dysplastic conjunctiva ass w/ sun and wind exposure
Becomes pterygium when it grows onto cornea
Signs/sx: sudden eye pain and redness when inflamed
Tx: ATs for comfort, +/- surgical excision of pterygium if visually significant
Sunglasses when outside, lubrication
Fluorescein Staining
Fluorescein dye stains corneal basement membrane exposed by corneal epithelial defects
Corneal Abrasion
Hx FB, trauma, CL
Signs/sx: Severe pain, redness, tearing, light sensitivity, +/- blurred vision
Dx: pain improves w/ proparacaine, epithelial defect stains w/ fluorescein
Tx: time, abx ointment for comfort & prophylaxis
Corneal Foreign Body
Lodged on corneal surface
Signs/sx: Pain, tearing, redness, photophobia, FB that stains w/ fluorescein
Tx: Remove w/ wet cotton tip, 30g needle or burr (refer), abx drops for prophylaxis
When to refer? If needle or burr needed to remove, high speed injury
Often occurs w/ metalworkers, grinder use
Corneal ulcer
Serious cornea infection
Hx FB, trauma, CL
Signs/sx: Severe pain, redness, tearing, light sensitivity, blurred vision, white corneal infiltrate that stains w/ fluorescein
Tx: Scrapings/culture, intensive medical management w/ drops, +/- surgical intervention
*SAME DAY referral to OPHTHO**
Herpetic Keratitis
Ocular infection w/ HSV involving corneal epithelium
Classically dendritic lesion w/ fluorescein
HSV can cause disease anywhere in eye
Tx: Oral acyclovir
Refer in 1-2 days
Chemical injuries
OCULAR EMERGENCY
Acid v. alkali
Denaturing proteins –> permanent vascular ischemic damage
Flush immediately
Check pH, evaluate for surface damage & presence of limbal ischemia!
Red eye = better; Whitening around cornea = ischemia concern & stem cell deficiency
Further tx: ab drops, tetanus, pain relief
SAME DAY REFERRAL
Alkali chemical injury
More damaging
Lipophilic
Penetrates tissue rapidly
Acidic chemical injury
Protein coagulation of corneal epithelium,
More superficial injury
Dry Eyes
Common cause of eye irritation, redness
Seen in post-menopausal women, systemic conditions like Sjogren’s patients with blepharitis
Signs/sx: dry scratchy, irritated, tearing, +/- blurred vision, puctuate corneal staining
Tx: ATs, ointment
Refer if no improvement (could be punctal plug)
Anterior Uveitis
Inflammation of iris & ciliary body
Ass w/ collagen vascular disease (lupus, HLA B-27)
Signs/sx: eye pain, photophobia, blurred vision, perilimbal flush +/- poorly reactive or irregular pupil, AC cell/flare
No improvement w/ proparacaine eye drops
Tx: Topical steroids, Cycloplegia
Same day referral
Acute angle closure glaucoma
Sudden increase in IOP caused by obstruction of eye’s drainage system
Signs/sx: deep pressure/pain or HA, halos, vision loss, NV, fixed mid-dilated pupil, narrow AC, corneal edema (blunted light reflex), IOP>30!!
OCULAR EMERGENCY!! IMMEDIATE REFERRAL!! - damages nerve tissue
T: pressure lowering eye drops +/- diamox, laser iridotomy
Endophthalmitis
Infection w/in eye
Exogenous: entry wound after trauma or surgery (w/in 2 weeks is greatest risk)
Endogenous: Spread of infection from another body source (rare)
OCULAR EMERGENCY
Tx: aspiration of ocular fluid for culture, injections of abx
True Emergency
Gonococal conjunctivitis Chemical injury Orbital cellulitis Acute angle closure Endophthalmitis
Same Day Referral
Anterior uveitis
Corneal ulcer
Corneal foreign body
Episcleritis/scleritis
Refer in 1-2 days
Preseptal cellulitis
Corneal abrasion
Herpers zoster ophthalmicus (faster if vision diminished)
Herpetic keratitis
Refer if no improvement
Chalazion/hordeolum blepharitis dry eye dacryocystitis viral or bacterial conjunctivitis subcong hemorrhage pinguecula/pterygium
