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Chapter 19 – Red and Painful EyeNOTE: CONTENT CONTAINED IN THIS DOCUMENT IS TAKEN FROM ROSEN’S EMERGENCY MEDICINE 9th Ed. Italicized text is quoted directly from Rosen’s. Key Concepts:Critical diagnoses, such as caustic injury, orbital compartment syndrome, and acute angle closure glaucoma, require immediate treatment and ophthalmology consultation.Prompt and prolonged irrigation is advised for patients who experience caustic injury to the eye.Headache and nausea may be prominent symptoms in acute angle-closure plete abolition of a foreign body sensation after instillation of local anesthesia solution indicates a high likelihood of a superficial corneal lesion.Keratitis, inflammation of the cornea, is most commonly caused by a viral infection, but may also be caused by recent ultraviolet light exposure, chemical injury, or hypoxic injury from contact lens use.A localized corneal defect with edematous, inflammatory changes may signal corneal ulceration.A corneal dendritic pattern may signal a herpetic infection, which can progress to corneal opacification and visual loss.Pain, consensual photophobia, perilimbal conjunctival injection, and a miotic pupil that is caused by ciliary spasm could signal iritis, which is inflammation of the iris and ciliary body, and the choroids. The cause may be trauma or underlying autoimmune disease. The presence of cells and flare in the anterior chamber can identify these conditions.Conjunctivitis is usually self-limited and rarely requires antibiotic treatmentRosen’s in PerspectiveOcular pathology represent, for some, the most frightening diseases out there. And while the vast majority of cases that you will see in the ED will not be vision-threatening, you have to keep your eyes peeled. This episode of CRACKCast reviews Chapter 19 in Rosen’s 9th Edition - Red and Painful Eye. We will cover all of the pertinent information to best equip you for your next ED shift. We will start by giving you a solid approach to the history and physical examination for the patient complaining of having an angry peeper. Then, we will give you a solid differential to consider for patients with ocular complaints. Last, we will share some short snappers to look like a rockstar during your next consultation with your friendly neighbourhood Ophthalmologist.So, sit back, take a sip of your coffee, and jump on in. This is a bit of a long one, so don’t be afraid to take it in chunks. As always, be sure to use this as an adjunct for your learning. Reference the text, run through the flashcards, listen to the podcast, rinse, and repeat. Spaced repetition is key! Core Questions: Detail the pertinent points to review when taking the history of a patient presenting with a red and painful eye - Box 19.2Outline an approach to the ocular physical examination - Box 19.3Outline the components of the slit lamp examination - Box 19.4 What signs and symptoms, if present, likely indicate the presence of serious ocular pathologies - Box 19.1What is a relative afferent pupillary defect and what conditions cause it?List ten causes of increased intraocular pressureList five causes for an absent red reflex - Box 19.5Name three critical, emergent, urgent, and non-urgent causes of the red and painful eye? - Figure 19.8Wisecracks: What are the fundoscopic findings of a central retinal artery occlusion?What is the pinhole test and what visual disturbances does it correct?What are the three most common causes of an irregularly shaped pupil?What is Seidel’s Test and what condition does it identify?Core Questions:[1] Detail the pertinent points to review when taking the history of a patient presenting with a red and painful eye - Box 19.2Of course, everyone will have their own approach to taking a clinical history to elucidate the cause of the patient’s red and painful eye. However, it is important that everyone do their best to clarify the following points:Determine whether the cause of their symptoms are the result of a recent ocular traumaDetermine whether or not any exposure to caustic substances or irritants brought about the patient’s symptomsCharacterize the pain, paying particular attention to the following:PQRSTU featuresProvocative/palliative factorsDetermining if opening/closing the eyes exacerbates the pain is keyUnderstanding the effects of bright light or dark settings on the pain is importantQuality of painItching tends to be more associated with blepharitis/conjunctivitis/dry eye syndromeBurning is often associated with episcleritis, limbic keratoconjunctivitis and superficial irritation of the pterygium or pingueculaeSharp pain is generally indicative of pathology in the anterior chamberDull pain is often associated with increased intraocular pressure Radiation of pain to adjacent anatomic structuresSeverityTimingPatient’s understanding of painPresence or absence of a foreign body sensationThe presence of a foreign body sensation is a strong indicator of corneal damage or injuryPresence of lid swelling, tearing, discharge, crustingSensation of light sensitivityUse of contact lenses TypeHow often are they cleanedHow often is the lens solution changedUse of corrective lensesWhen was their last assessmentHas there been any subjective change in vision despite use of corrective lensesHistory of ocular surgeryHistory of systemic diseases that may affect the eyeMedications that the patient is takingPresence of any known or suspected allergies[2] Outline an approach to the ocular physical examination - Box 19.3Complete Eye ExaminationVisual AcuityUse the best possible score using their corrective lensesVisual FieldsDone via using confrontation methodExternal ExaminationGlobe position in orbitConjugate gazePeriorbital soft tissues, bones, and sensationExtraocular Muscle MovementPupillary EvaluationDirect IndirectSwinging Light TestPressure DeterminationMultiple devices available for testingSlit-lamp ExaminationFundoscopic Examination[3] Outline the components of the slit lamp examination - Box 19.4 Slit Lamp ExaminationLids and LashesInspected for blepharitis, lid abscess (ex. hordeolum) and internal or external pointing, and dacrocystitis Conjunctiva and scleraInspected for punctures, lacerations, and inflammatory patternsCornea (with and without fluorescein)Evaluated for abrasions, ulcers, edema, foreign bodies, or other abnormalitiesAnterior chamberEvaluated for the presence of cells (ex. red and white blood cells) and “flare” (diffuse haziness related to cells and proteins suspended in aqueous humor) representing inflammation. Hyphema from surgery or trauma, hypopyon, or foreign bodies may also be notedIrisInspected for tears or spiraling muscle fibers noted in acute angle-closure glaucomaLensExamined for position, general clarity, opacities, and foreign bodies[4] What signs and symptoms, if present, likely indicate the presence of serious ocular pathologies - Box 19.1Pivotal Findings More Likely Associated With a Serious Diagnosis in Patients with a Red or Painful EyeSevere ocular painPersistently blurred visionExophthalmos (proptosis)Reduced ocular light reflectionCorneal epithelial defect or opacityLimbal injection (also known as “ciliary flush”)Pupil unreactive to a direct light stimulusWearer of soft contact lensesNeonateImmunocompromised stateWorsening signs after three days of pharmacologic treatment[5] What is a relative afferent pupillary defect and what conditions cause it?Ahhh, the RAPD. A physical examination finding that pops up on every medical school, in-training, and Royal College answer sheet from time to time. And while we often continually review it, its definition and associated conditions often elude us come test time. So, review this often and take time to truly scrutinize the physiology here so this important concept solidifies in your mind.A relative afferent pupillary defect, or RAPD, is defined as a pathologic dilation of both eyes when a bright light is swung from the patient’s normal eye to affected eye.Let’s break it down here. A RAPD indicates a pathology in the afferent pathways that allow for consensual pupillary restriction to take place. So, information, at least in part, is not being transmitted along the afferent pathway of one eye. So, when you shine a light in the affected eye, there will be some degree of consensual constriction of both pupils. When you then swing the light to the unaffected eye, the pupils will restrict to an even greater degree, as there is no impediment to the neural impulses along that tract. When you then swing the light back to the affected eye, the eyes will actually dilate, as the stimuli that result in consensual reaction are running along a flawed neural pathway. Some conditions that can cause a RAPD are the following:Vitreous hemorrhageRetinal detachmentRetinal ischemiaOptic neuritis[6] List ten causes of increase intraocular pressureThis in no way is a comprehensive list, but should give you some accolades on your next off-service ophthalmology rotation:Acute angle-closure glaucomaOpen-angle glaucomaVitreous hemorrhageOrbital cellulitis/abscessRetrobulbar hemorrhageHyphemaIritis with hypopyonChronic steroid eye drop useEnopthalmitis Incorrect measurement techniqueOcular malignancyVomitingOcular trauma[7] List five causes for an absent red reflex - Box 19.5Causes of Inability to Visualize a Red Reflex or the Optic FundusOpacification of the cornea, most commonly by edema secondary to injury or infectionHyphema or hypopyon within the anterior chamberExtremely miotic pupilCataract of the lensBlood in the vitreous or posterior eye wallRetinal detachment[8] Name three critical, emergent, urgent, and non-urgent causes of the red and painful eye and describe their treatment? - Figure 19.8Potential DiagnosisManagementConsultationDispositionCaustic Kerato-conjunctivitisImmediate and copious irrigation with tap water or sterile normal saline until tear-film pH = 7Solids - lift particles out with dry swabs before irrigationFor acidic exposures, minimum irrigation volume is 2L over 20 minutesFor alkali exposures, minimum irrigation volume is 4L over 40 minutesConsult Ophthalmology if there is any abnormal visual acuity, objective findings on exam after sufficient irrigation with the exception of expected injection of conjunctiva secondary to treatmentMay discharge only if tear film pH = 7 and no findings on examination except conjunctival injection, ophthalmologist can reevaluate next dayOrbital Compartment Syndrome(OCS)Measure IOP unless possibility of ruptured globe; IOP > 30 mmHg may require emergent needle aspiration or lateral canthotomy and cantholysis in EDIOP > 20 mmHg may be a surgical emergency, may add medications used in glaucoma to decrease IOP before decompression in the EDObtain axial CT of brain and axial and coronal CT of the orbits/sinusesAdmit all cases of retrobulbar pathology causing increased IOP. Others might be candidates for discharge depending on the cause of the problem.Retrobulbar HematomaCorrect any coagulopathy or thrombocytopeniaSee OCSSee OCS Retrobulbar EmphysemaAntibiotic coverage to prophylactically cover sinus floraSee OCSSee OCSRetrobulbar AbscessAntibiotics (as in the case of orbital cellulitis below)See OCSSee OCSScleral PerforationProtect eye from further pressure, provide pain relief, and prevent vomitingParenteral antibiotics and tetanus prophylaxisOphthalmologist must come to ED if there is any concern for globe penetrationAdmit for continuation of antibiotics and possible procedural interventionHyphemaFirst rule out open globeMay require ultrasound if cannot visualize posterior structuresMeasure IOP unless possibility of open globeIOP > 30 mmHg may require acute treatment as in glaucoma; if IOP > 20 mmHg and no iridodialysis, may use cycloplegic to prevent iris motionDiscuss findings and use of aminocaproic acid and steroids, other medical therapy, best disposition, and follow up examination by an ophthalmologist within 2 daysSome patients may be admitted for observation, bed rest, head elevation, frequent medication administrationMost patients can be discharged with careful instructions to return for any increased pain or change in visionPatients should decrease physical activity and sleep with an eye shield in placeEyes should be left open when awake s that any change in vision can be immediately recognizedPO NSAIDs for analgesiaSub-conjunctival HemorrhageExclude coagulopathy or thrombocytopenia if indicated by historyNone required if no concerns for underlying ocular pathology and no acute complicationsReassure patient that discoloration should resolve over 2 to 3 weeksCorneal PerforationProtect eye from further pressure, provide pain relief, and prevent vomitingParenteral antibiotic and tetanus prophylaxis requiredOphthalmologist must come to the EDAdmit for continuation of antibiotics and procedural interventionRuptured GlobeProtect eye from further pressure, provide pain relief, and prevent vomitingParenteral antibiotic and tetanus prophylaxis requiredOphthalmologist must come to the EDAdmit for continuation of antibiotics and procedural interventionCorneal AbrasionAntibiotic prophylaxis with polymyxin-B/trimethoprim solution 1 drop every 3 hours while awake and erythromycin ointment while sleepingDiscuss plan for follow-up in 1 to 3 daysMay discharge if no other findings. No patch.Traumatic MydriasisNone once other abnormalities of the eye, cranial nerves, and brain have been reasonably excludedDiscuss plan for follow up evaluation of slowly developing hyphema and ensure resolutionMay discharge if no other findingsInflammatory PseudotumorEvaluate IOP, evaluate for DM and vasculitis with CBC, basic metabolic panel, UA, and CRP or ESRObtain axial CT of brain and axial and coronal CT of orbits and sinusesIOP >20 mmHg may be surgical emergency, may add medications used in glaucoma to decrease IOP before decompression in EDMay discharge if no systemic problems, no findings of particular concern on CT, and IOP <20 mmHg. Start high-dose steroids after discussion with ophthalmologist, and ensure reevaluation in 2 to 3 daysOrbital CellulitisMeasure IOP and rule out orbital compartment syndromeStart parenteral antibiotics with second generation cephalosporin or with ampicillin/sulbactam to cover skin and sinus flora IOP >20 mmHg may be surgical emergency, may add medications used in glaucoma to decrease IOP before decompression in EDObtain blood cultures and start antibioticsAxial and coronal CT of orbits and sinuses to rule out FB, retrobulbar abscess, orbital gas, subperiosteal abscess, osteomyelitis, and changes in cavernous sinusConsider LPAdmit all cases of orbital cellulitisPeriorbital CellulitisFirst rule out orbital cellulitisPO antibiotics for sinus and skin flora if not admittingOphthalmologist may admit if systemically ill, case in moderate or severe, or no social support for patientMay discharge mild cases with PO antibioticsOphthalmologist must reevaluate next day to ensure no orbital extensionDacryo-cystitis and Dacryo-adenitisFirst rule out orbital cellulitis and periorbital cellulitisInspect for obstruction of punctum by SLE, may express pus by pressing on sac, PO antibiotics for nasal and skin flora if not admittingOphthalmologist may admit if systemically ill, in case of moderate or severe, or no social support for patientAsk about culturing before prescribing medications if admitting, and then may add medications used in glaucoma to decrease IOP before decompressionMay discharge mild cases with PO analgesics and antibioticsApply warm compresses to eyelids for 15 minutes and gently massage inner canthal area four times a dayOrbital TumorMeasure IOPEvaluate for extraocular signs of malignancyObtain axial CT of brain and axial and coronal CT of orbits and sinusesIOP > 20 mmHg may be a surgical emergency, prescribe to decrease IOP in EDOphthalmologist may want MRI, MRA, or orbital ultrasonographyBased on findings and discussion with consultantHordeolumExternal - warm compresses often all that is needed, may prescribe anti-Staphylococcus ointment BIDInternal - PO antibiotics for beta-lactamase StaphylococcusOutpatient referral only for treatment failure after two weeksDischarge with instructions to apply warm compresses to eyelids for 15 minutes four times daily and gently massage abscess four times dailyBlepharitisNone, except artificial tears for dry eyeOutpatient referral only for treatment failure after two weeksDischarge with instructions to apply warm compresses to eyelids for 15 minutes four times daily and scrub lid margins and lashes with mild shampoo on washcloth twice dailyChalazionNoneOutpatient referral only for treatment failure after two weeksDischarge with instructions to apply warm compresses to eyelids for 15 minutes QID, gently massage nodules QIDAcute Angle-Closure GlaucomaAdminister medications below in ED if IOP >30 mmHgReduce humor volume:-Timolol 0.5% 1 drop-Apraclonidine 1%, 1 drop q8hr-Dorzolamide 2% 1 drops, if SCD or trait then methazolamide 50 mg PODecrease inflammation:-Prednisolone 1%, 1 drop q 15 min x 4Constrict pupil:-Pilocarpine 1%-2% 1 drop after IOP <50, repeat in 15 minConsider osmotic gradient:-Mannitol 2g/kg IVDiscuss any IOP >20 mmHg with OphthalmologistBased on findings and discussion with consultant, which primarily depends on speed of onset and response to treatment Keratitis (abrasion or UV Injury)First, rule out corneal penetration either grossly or employing Seidel’s testRelieve blepharospasm with topical anestheticInspect all conjunctival recesses and superficial cornea for any foreign material that can be removed by irrigation or manually lifted from surfaceOphthalmologist must come to the ED if there is any concern for globe rupture or penetration.Otherwise, consult for follow up examination in 1-2 daysDischarge if not infected or ulceratedMay provide topical antibiotics using polymyxin B with bacitracin or trimethoprimErythromycin, gentamycin, and sulfacetamide are less desirable single-agentsPO NSAIDs or narcoticsNo patchKeratitis (ulceration)Relieve pain and blepharospasm with topical anestheticStaph/Strep species still most common, but Pseudomonas greater percentage in existing infections (especially contact lens wearer), so prescription with topical fluoroquinolone is preferredDiscuss with Ophthalmologist any potential need to debride or culture before starting antibioticBased on findings and discussion with consultantTopical ciprofloxacin (2 drops q 15 min for 6 hrs, then 2 drops q 30 min for first 24 hrs until consultant sees next day)Topical moxifloxacin (1 drop q 15 min for 1 hr, then 1 drop q 1 hr for 24 hrs until consultants sees next day)Lesion near the visual axis or large need fortified antibiotics (tobramycin)Keratitis (herpetic infection)Relieve pain and blepharospasm with topical anestheticPrescribe acyclovir 3% ointment, trifluridine 1% solution, or vidarabine ointmentVCV and CMV not normally given antivirals if immunocompetentDiscuss with Ophthalmologist any potential need to debride or culture before starting antiviralBased on findings and discussion with consultantTypical vidarabine or acyclovir dosing is five times daily for 7 days, then taper over 2 weeksTypically trifluridine dosing is 1 drop every 2 hours for 7 days, then taper over 2 more weeksPO NSAID’s or narcotics for analgesiaNo patchScleritisDecrease inflammation with PO NSAIDsDiscuss findings and use of topical or PO steroidsMay discharge patient with medications recommended by ophthalmologist and ensure reevaluation in 2-3 daysAnterior Uveitis and HypopyonFirst rule out glaucoma with IOP measurementPrescribe in ED if IOP > 20 mmHgOtherwise acceptable to dilate pupil with 2 drops of cyclopentolate 1%Discuss findings and use of prednisolone acetate 1% (frequency determined by Ophthalmologist but range is every 1 to 6 hours)May discharge patient with medications recommended by Ophthalmologist and ensure reevaluation in 2-3 dayPatients with hypopyon are generally admittedEndophthal-mitisEmpirical parenteral antibiotic with vancomycin and ceftazidime to cover Bacillus, Enterococcus, or StaphCiprofloxacin or levofloxacin when others contraindicatedOphthalmologist must admit for parenteral and possibly intravitreal antibioticsAdmit all cases of endophthalmitisKerato-conjunctivitisTreat for conjunctivitis by likely etiologic categoryDiscuss findings and use of prednisolone acetate 1% (frequency determined by ophthalmologistMay discharge patient with medications recommended by consultant, ensure reevaluation in 2-3 daysEpiscleritisRelieve irritation with artificial tears and decrease inflammation with ketorolac dropsOutpatient referral only for treatment failure in 2 weeksMay discharge patient with PO NSAIDs +/- topical ketorolacInflamed PingueculaDecrease inflammation with naphazoline or ketorolac dropsOutpatient referral only for treatment failure after 2 weeksDischarge to follow-up with Ophthalmologist for possible steroid therapy or surgical removalInflamed PterygiumBacterial ConjunctivitisTopical polymyxin-B/trimethoprim in infants and children, because more StaphTopical sulfacetamide or gentamycin clinically effective in 90% of uncomplicated adult ical fluoroquinolone if Pseudomonas possibleCulture drainage and Ophthalmology consult in all neonates and those at risk for vision loss or systemic sepsisNeisseria gonorrhoeae can be rapidly sight-threateningDischarge uncomplicated cases within 10 days of topical antibiotics bilaterally regardless of infection laterality Use ointments in infants and drops in othersChlamydia Conjunctivitis Empirical PO azithromycinConsider empirical parenteral ceftriaxone for concurrent N. gonorrhoeaeCulture drainage and consult in all neonates and those at risk for vision loss and systemic sepsisDischarge uncomplicated cases on 5 days of PO azithromycinContact Dermato-conjunctivitisIrrigation with tap water or sterile normal salineDecrease irritation with naphazoline dropsOutpatient referral only for severe cases or treatment failure after 2 weeksIdentify offending agent and avoid subsequent exposure. Discharge uncomplicated cases on naphazolineToxic ConjunctivitisAllergic ConjunctivitisDecrease irritation with naphazoline dropsOutpatient referral only for severe cases or treatment failure after 2 weeksIdentify antigenConsider treating other allergic symptoms with PO antihistaminesViral ConjunctivitisDecrease irritation with naphazoline drops, or ketorolac dropsCulture drainage, consult Ophthalmology in all neonates and those at risk for vision loss or systemic sepsisAsk about pregnant mothers, infants, and immunocompromised individuals in close contactDischarge uncomplicated cases with instructions on respiratory and direct-contact contagion for 2 weeksWisecracks: [1] What are the fundoscopic findings of a central retinal artery occlusion?Answer:Remember, think of a central retinal artery occlusion (CRAO) in the patient with painless acute onset vision loss. On fundoscopic exam, look for the following:General pallor of the retinaAttenuation of the retinal arteriesAttenuation of the retinal veins[2] What is the pinhole test and what visual disturbances does it correct?Answer:The pinhole test is a commonly-employed exam technique that is used by ophthalmologists to eliminate the influence of refractive errors that result in visual disturbances. By making the patient look through several small holes poked through a piece of paper, only light beams that enter the lens perpendicularly are allowed to pass. Thus, the influence of refractive errors are eliminated. If the patient’s visual acuity does not improve with the pinhole test, they have a non-refractive visual deficit, and as such, you should do additional testing. If it corrects, your patient may just need a set of coke bottle glasses![3] What are the three most common causes of an irregularly shaped pupil?Answer:Blunt or penetrating traumaPrevious surgerySynechiae from prior iritis or other inflammatory conditions[4] What is Seidel’s Test and what condition does it identify?Answer:Seidel’s Test is a non-invasive way to determine if there has been a corneal perforation. After instillation of the fluorescein dye, look at the patient’s eye under the cobalt blue light. If you see a waterfall-like flow from a portion on the cornea, the test is positive, indicating that aqueous humor is flowing through a corneal defect diluting and displacing the dye. ................
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