THE RED AND PAINFUL EYE

Olivier Lavigueur

ER PGY-1

July 21 2014

ANATOMY

PHYSICAL EXAM – VVEEPP + TOOLS

In the context of a red and painful eye:

Visual Acuity (Visual Fields) External examination Extraocular movements Pupils Pressure (normal < 20 mmHg)

Fundoscopy and Slit lamp

SLIT LAMP

ROSEN’S APPROACH TO THE RED EYE

Do you think anything got into your eye? What could it be?

Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or

limbal injection? Focal redness of bulbar conjunctiva? Purulent discharge? Itching? Topical med, makeup?

CASE #1

APPROACH TO CASE #1

Do you think anything got into your eye? Yes

What could it be? DO SOMETHING!!!

Caustic Injury? Most likely

CAUSTIC INJURY

CAUSTIC INJURIES

BAAAAD Irrigation, irrigation irrigation (> 30 min) until

pH of tear is neutral If solid caustic agent present (look carefully),

remove with dry cotton swab before irrigating. Alkali worst than acids Opthalmology consultation, topical antibiotic,

cycloplegics, cross fingers

TRIVIA

CASE #2

CASE #2

APPROACH TO CASE #2

Do you think anything got into your eye?

Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or

limbal injection? Focal redness of bulbar conjunctiva?

Yes

SUBCONJUNCTIVAL HEMORRHAGE

Well demarcated at the limbus

Flat, smooth, brightred, limited tobulbar conjunctiva

Often occurs as a result of trauma orvalsalva

Not painful

DC home, cold compress

TRIVIA

CASE #3

CASE #3

Pain ++, sudden onset Was in the basement Now, sensitive to light Nausea and vomitting Can’t see well out of affected eye

APPROACH TO CASE #3

Do you think anything got into your eye?

Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or

limbal injection? Yes

ACUTE ANGLE-CLOSURE GLAUCOMA

Pupillary block of aqueous humor

Precipitated by pupillary dilation Darkness Emotional upset Anticholinergics Sympathomimetic

s Rapid rise in IOP Leads to damage

to the optic nerve up to blindness

ACUTE ANGLE CLOSE GLAUCOMA

Treatment Visual acuity reduced to hand movements

Topical Beta blocker (Timolol) Sympathomimetic (Pilocarpine) Alpha 2 agonist (Apraclonidine) Steroid (Prednisolone)

IV Carbonic anhydrase inhibitor (Acetazolamide) Osmotic agent (Mannitol)

Visual acuity just blurry, IOP < 30 mmHg Mannitol and pilocarpine not required.

In both cases, consult Ophtalmology (surgery)

TRIVIA

CASE #4

CASE #4

Pain Photophobia Slightly blurry

vision

APPROACH TO CASE #4

Do you think anything got into your eye?

Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or

limbal injection? Yes

HYPHEMA

Spontaneously resolve Complications include:

Rebleed Corneal blood staining IOP

Classic management Antifibrinolytics Raise head, bed rest Cycloplegics Steroids

…. No effect

GHARAIBEH A, ET AL.: MEDICAL INTERVENTIONS FOR TRAUMATIC HYPHEMA.

We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review.

[Patients] who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients on aminocaproic acid take longer to clear.

MANAGEMENT

Rule out globe rupture (US) If:

Small hyphema (less than 50%) No vision loss No IOP No hemoglobinopathy (sickle cell)

Conservative management

If not, patient would benefit from ophtalmological follow up and IOP management

PATIENT COMES BACK!!

Complaining of increasing pain Painful and reduced ocular movements Decreased visual acuity

Notice he looks familiar

RETROBULBAR HEMATOMA

Injury to orbital vessels Hemorrhage in a confined space Increased pressure Compromise of vessels and optic nerve

Needs urgent decompression

RETROBULBAR HEMATOMA

Medical Topical beta blocker (timolol) IV carbonic anhydrase inhibitor (acetazolamide) IV osmotic agent (mannitol)

Surgical Lateral cathotomy Needle aspiration Surgical decompression of hematoma

TRIVIA

CASE 5

36M, comes with eye pain Sudden onset Sawing through a piece of metal No eye protection

APPROACH TO CASE #5

Do you think anything got into your eye? Yes

Do you know what it could be? A piece of metal

SLIT LAMP EXAM

• Patient is immediately relieved with topical analgesia

SEIDEL TEST

To rule in a corneal penetration Place a fluorescein strip over the abrasion Quick dilution of the concentrated fluorescein

by leaking aqueous humor

IMAGING

Ultrasound more sensitive, but CT delineates damage better

KERATITIS + PERFORATION

Pain Foreign body sensation Tearing Injected conjunctiva Blepharospasm History often supportive Don’t forget to look under the eyelids!

Can also occur with: Insects UV light (arc welding)

MANAGEMENT – FOREIGN BODY

No penetration Removal of FB

Irrigation Cotton tip Do no use syringe, use small IV catheter

Rust rings from ferrous FB best removed the following day

Topical antibiotics, no need for patch Opthalmology if symptoms do not improve

If penetration suspected Consult opthalmology to determine damage

extent NO MRI!!

REFERENCES

Chapters 22 and 71 – Rosen‘s 8th edition 

Gharaibeh, A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005431.

SGEM #18: Eye of the Tiger.http://thesgem.com/2013/01/sgem18-eye-of-the-tiger/