The Red Eye. RED EYE HISTORY Serious Symptoms ACUITY PAIN PHOTOPHOBIA.
Post on 21-Jan-2016
The Red Eye
RED EYE HISTORYSerious Symptoms
RED EYE HISTORYDischarge (character and quantity)Itch, scratch, burnTrauma, exposure to particlesAssociated URI, Sick Contacts
LID FOLLICLES - CHLAMYDIA OR NOT?
Subconjunctival hemorrhageNo good slidecompletely benignnormal acuity, etc
REVIEWAcuity, pain, photophobia in association with red eye are worrisomeCheck conjunctivae, acuity, pupil, corneaOften hard to distinguish causes of conjunctivitis - ok to use abx when in doubtConjunctivitis is contagiousAcute glaucoma - vomiting patient with dilated pupil
Slide 1 - The Red EyeToday we review one of the common problems seen in primary care, the Red Eye
The main goal is to learn to triage the few problems that require urgent referral to ophthalmology from others. Another goal is to recognize common problems that present as red eye(s) and initiate treatment.
This should be possible with a good history and examination. The equipment needed for an adequate exam: a pen light or opthalmoscope. Fluorescein dye strips are a good extra, and a tonometer is nice but neither is truly necessary in most situations and a slit lamp is almost never necessary.Slide 2 Review the Anatomy of the Eye - Anatomical DiagramPoint out the lids - with the mebomium glandsPoint out the conjunctivaPoint out the cornea, which covers the anterior chamberThe iris is roughly the same things as whats labeled the ciliary body - its the muscle fibers projecting over the lens
Red eye history serious symptoms
The most important part of the history is to ask about visual acuity. If its preserved, youre probably not dealing with a serious disorder.
Similarly, the absence of eye pain and photophobia are very reassuring.
Well get into specifics of eye pain when discussing specific diagnosesRed Eye History ask about all of the above
Discharge usually suggests conjunctivitis; can be seen with iritis. Purulent discharge suggests bacterial conjuntivitis.
Itching etc. also suggests conjunctival irritation
Ask about blunt trauma and exposure to particles (wood or metal dust etc.) that might cause corneal ulceration or injury
Ask about URIs and sick contacts. Most conjunctivitis is viral; often associated with recent upper respiratory symptoms. Easily transmissible by direct contact .We will discuss several components of the exam of the Red Eye stopping along the way to discuss some of the diagnostic entities. At the end well review the H & P for each of the main diagnosesExam Acuity
Check the acuity with a Snellen chart. If the patient is 20/20 youre not going to blow a serious diagnosis.
Check with the patients distance glasses on. If you have a pinhole occluder, use that. It corrects all refractive errors (which youre not interested in at the moment). You can make a pinhole occluder out of the patients blue card by poking holes in it with an eighteen gauge needle!Injection
Look closely at the injection? Is it mostly peripheral or does it extend to the limbus? Its definitely not a100% reliable sign, but conjunctivitis is generally a pattern of peripheral injection; a more central ciliary flush pattern can be associated with keratitis, iritis or glaucomaCONJUNCTIVITIS
Most common cause of red eye. Visual acuity is preserved. Pain and photophobia absent. Rest of exam normal.
Purulent discharge suggests bacterial, otherwise discharge not discriminative.
VIRAL - most common. Often associated URI or contact with pink eye. Often begins one eye, spreads to other. There is some data that treatment with broad spectrum antibiotic drops - TMP + Polymixin or Sulfacetamide shortens course. Infectious for many days . If youre working at Sloan-Kettering or someplace else where patients are very susceptible to viral infection, a good case of viral conjunctivitis may buy you 2 weeks sick leave!
ALLERGIC - can be diagnosed with history of similar episodes, exposure to allergens, associated other atopic symptoms. Treat with topical antihistamine (OcuHist over-the-counter, Vasocon, or levocabastine).BACTERIAL CONJUNCTIVITIS
History: Abrupt onset, first one eye, then the other, purulent dischargeOften cant distinguish very well from severe viral. Use topical gentamicin or tobramycin.Watch out for hyperacute bacterial conjunctivitis - severe discharge from gonococcal infection, often with swelling of the lids. Suspect with appropriate sexual history. Refer urgently, treat GC.
CONJUNCTIVITIS - sometimes you see hypertrophied lymphoid follicles on the lids. Usually this is fromallergy or virus, however can be associated with sexually transmitted chlamydia. Check for sexual history and other evidence of chlamydial infection. Genprobe. Show next slide too
If in doubt, treat with oral doxy or azithromycin. Chlamydia or not? Same as beforeEPISCLERITIS
The episclera lies beneath the conjunctiva and over the sclera. Episcleritis is an autoimmune, usually self-limited inflammation of the episcleral vessels.
The hallmark is focal inflammation often involving just one sector of the eye. Radially oriented dilated vessels can be seen with white sclera in between. The eye may be slightly tender, even when closed.
The history is usually rapid onset of pain (a dull ache) and redness. ACUITY is normal.
Treat with NSAID, non-emergent ophtho referral.IRITIS/IRIDOCYCLITIS (SAME THING) SHOW THIS SLIDE AND NEXT
Inflammation of the iris (anterior uveitis) is characterized by a history of: pain (a deep ache) and photophobia. Every time the pupil constricts the iris moves and and an inflamed muscle is asked to move. There is often pain when light is shined in the other eye (consensual photophobia).
Continuing with our discussion of the eye exam, the PUPIL is an important part. Note the size, reactivity, and shape.
With iritis, the exam shows: injection with a circumlimbal (central) pattern. There may be slight discharge present. Acuity is decreased in the affected eye. The pupil is constricted in spasm and smaller than that of the unaffected eye. There may also be a hypopyon - a mensiscus created by settled white cells in the anterior chamber. With a slit lamp, white cells can be seen floating around. Iritis can cause all sorts of permanent damage
Refer to ophtho urgentlyThis hypopyon is not secondary to iritis, but a corneal ulcer. But this is what hypopyon looks likeACUTE GLAUCOMA
Pupil exam: In acute glaucoma the pupil is almost always fixed (unreactive) and moderately dilated and deformed into an oval shape.
The history is one of rapid onset of red eye with severe pain. Usually there is associated vomiting and prostration. Clinically not subtle. Sometimes the patient complains of seeing haloes around lights. Patient usually very sick-looking.
Exam: Pupil as above, almost always a unilateral problem. Acuity is decreased in the affected eye. The conjunctiva is red often with a central pattern of injection. Often simple gentle palpation of the two eyes will reveal that the affected eye is hard. The cornea sometimes looks steamy from edema. As above
Treatment: immediate referralPoor Mans Gonioscopy
shine a penlight from the side. If the anterior chamber is shallow, you may see a shadow cast on the other side. Check against the good eye.Poor Mans GonioscopyQuick review of the pathogenesis of narrow angle (acute) glaucoma
Mention first that most glaucoma is the wide angle variety which is chronic and asymptomatic until slow visual loss occurs over years.
The above picture mostly self-explanatory. The part thats cut off says and the episcleral veinsCORNEAL abrasions and ulcerations are a common cause of red eye.
Continuing with the discussion of the eye exam, after checking the acuity, and examining the conjunctiva and the pupil, check under the eye lids to see if there are any foreign bodies or nicks.
Use a q-tip (or ballpoint pen) to evert the upper lid. Press against the upper orbit (not the eyeball), grab the lash and evert. CORNEAFluorescein dye paper (if available) is useful to improve visualization of corneal defects and inflammation in the cornea. (Often the defects can be seen with a pen light if you look carefully.) Fluorescein adheres to collagen fibers exposed when the cornea is denuded.
If you have ophthalmic anesthetic drops (ophthane), drop one drop in lower lid and note response to anesthetic. If its a corneal problem, the patient usually volunteers that he feels instantly better.
Then touch the fluorescein paper to the lower lid. Suspect a corneal problem when the patient complains of foreign body sensation or pain in the affected eye or when there is a history of exposure to particles.
On exam: look for evidence of herpeslook under the lidsusually peripheral injection pattern (unless bad keratitis)acuity normal, pupil normal+ fluorescein+ response to ophthaneshow next few slidesCorneal ulcers/ foreign bodies - try to irrigate out the particlesFastest healing part of the body - 1-1.5 days and it heals.Usually, no need for immediate referral if all foreign substance removed (otherwise the patient may continue scratching their cornea).
Keratitis with dendrites or widespread corneal inflammation should be referred.Other lesions which can cause red eyes
BlepharitisChalazions and styes
Styes are painful pimples arising from the base of hair follicles in the lid. They should be treated with soaks +/- topical antibiotics
Chalazions are painless chronic granulomas of the mebomium glands in the eyelids. If large or bothersome, should be removed by ophtho
This looks like a chalazionPingueculae are benign growths from the corner of the eyePterygia are also benign, non-emergent conditions that patients can be reassured about