Eye: Red Eye/Loss of Vision – ED

Eye: Red Eye/Loss of Vision

1. In patients with red eye, do not make a diagnosis of conjunctivitis without having first ruled out more serious possibilities (e.g., glaucoma, iritis, keratitis, foreign body).

Red Eye ddx: conjunctivitis, iritis, keratitis, acute glaucoma

• Painful with circum-corneal injection – Iritis, keratitis(corneal inflammation/FB), Acute glaucoma
• Discharge and diffuse conjunctival injection – conjunctivitis
• blurred vision – iritis, keratitis, acute glaucoma; intermittent w/ conjunctivitis that clears w/ blinking
• Pupil response: min with iritis & acute glaucoma
• cornea – opacification -keratitis; hazy – acute glaucoma

Non-traumatic red eye

1. Conjunctivitis
   1. Bacterial – purulent discharge on lids/lashes
      1. topical Abx
   2. Gonococcal – copious purulent, pre-aucicular adenopathy
      1. neonates 3-5 d post SVD
      2. Detected by culture
      3. Tx IV / IM cefuroxime / ceftriaxone, NS wash of eye, Full septic w/u
   3. Chlamydia – trachoma – pre-auricular adenopathy + conjunctival lymphoid follicles
      1. neonate 5-14d post SVD + otitis, PNA
      2. Detected by culture
      3. Tx topical erythromycin, IV tetracycline for 2-3 wk
   4. Viral – adenovirus, pre-auricular adenopathy, URI. serous/clear discharge
      1. complication: EKC – Epidemic Keratoconjunctivitis: ophthal, topical abx
   5. Allergic – cobblestone papillae under upper lid
      1. itching, tearing, stringy discharge
      2. Tx – cool compress, topical antihistamine
   6. Chemical – don’t neutralize acid/alkali by a buffer (heat causes damage)
      1. Alkali burn – EMERGENCY – liquefaction necrosis / rapid penetration
         1. immediate tap water & continuous saline irrigation up to 24hr – RL 500ml/30min; Goal pH 7-7.4 but irrigate till symptoms improve
      2. Acid burn – coagulation necrosis
         1. RL irrigation
2. Corneal inflammation / infection
   1. HSV – dendritic patter; Tx – oral & topical antiviral
   2. HZV – CN5, tip of nose (Hutchinson’s); pseudodendrite – ophthal consult to r/o retina involvement; Tx – ophthal consult; oral antiviral
   3. Corneal ulcer – bacterial/viral/fungal/chemical/Vit A deficiency
      1. painful, white flocculent cornea infiltrate
      2. +/- hypopyon
      3. Contact lens – pseudomonas
      4. topical fluoroquinolone / C&S / Imm ophthal consult
   4. UV keratitis – corneal flash burn “diffuse punctate keratopathy”
      1. Welder’s keratitis, snow blindness, tanning beds
      2. delayed symptoms, tearing, blurred, intense pain
      3. topical / oral anesthesia; prophylactic abx
3. Endophthalmitis – intraocular
   1. endogenous – baceteria/endocarditis
   2. Exogenous – eye Sx, intraocular FB
   3. Hypopyon – dec vision, floaters, pain, red
   4. Tx – ophthal – Intravitreal abx / vitrectomy + IV Abx
4. Iritis / Uvea
   1. iritis – anterior uveitis; cyclitis – intermediate uveitis; choroiditis – posterior uveitis
   2. Risk factors: trauma, infection (Lyme), autoimmune
   3. Decreased VA, consensual photophobia, ciliary flush
   4. Slit lamp: cells +/- flares in anterior chamber
   5. Tx: cycloplegics / topical steroids / mydriatics – cyclopentolate; ophthal consult
   6. c/i: posterior synechiae – iris adhere to lens; anterior synechiae – iris adhere to cornea (can lead to glaucoma)
5. Acute angle closure glaucoma
   1. IOP>30, steamy cornea, mid-dilated nonreactive pupil, n/v/headache
   2. Tx: definitive – peripheral iridotomy
      1. Timolol 0.5% drop (BB), alphaclonidine drop (alpha agonist) – reduce humor production
      2. Acetazolamide 500mg Iv/po x 1 to dec humor volume
      3. Pilocarpine 1% (cholinergic) Q15min (when IOP <40) to improve outflow
      4. Mannitol 2ml/kg IV
6. Scleritis – painful, autoimmune
   1. Anterior – diffuse, nodular, necrotizing
   2. posterior – complicated w/ retinal detachment, acute angle closure glaucoma
   3. Tx steroids
7. Episcleritis (contains small vessels – thin tissue between conjunctiva / sclera)
   1. benign, self-limiting Tx with NSAIDs, artificial tears

2. In a patient presenting with red eye or vision loss, obtain a detailed history of ocular symptoms (e.g., onset, progression, and previous episodes; trauma; pain; vision loss) and pertinent systemic illness (e.g., temporal arteritis, ankylosing spondylitis).

Acute visual loss

1. CRAO – true emergency
   1. sudden painless vision loss; thrombosis / thromboembolic, vasculitis/spasm
   2. RAPD (normal in amaurosis fugax), pale retina with pink dot near fovea (cheery-red macula)
   3. Tx – digital massage of anterior globe, Acetazolamide 500mg IV, Timolol 0.5%, carbogen / hyperbaric Ox / ophthal consult
2. Temporal arteritis – elderly >50
   1. headache, visual complaints, malaise, myalgia, wt loss, jaw claudication
   2. temporal artery tenderness/pulseless, swelling of optic nerve +/- RAPD
   3. Dx – ESR>100/CRP high; made by temporal artery biopsy
   4. Tx – IV methylprednisolone & ophthal consult
3. CRVO
   1. sudden painless vision loss / fundus – blood and thunder – no Tx
4. Optic neuritis – demyelinating inflammation of optic nerve
   1. loss of central vision + eye pain with EOM
   2. unilateral optic disc swelling; RAPD
   3. cause: MS
   4. Dx: clinical dx; MRI brain/orbit to assess demyelinating lesion
   5. Tx: IV steroids
5. Papilledema
   1. optic nerve swelling due to inc ICP
   2. Loss of vision; headache / N / V
   3. cause: HTN, ICB, intracranial mass; Idiopathic intracranial HTN
   4. Dx – bilateral papilledema; CT/MRI brain; LP to measure ICP
6. Solar retinopathy
   1. photocoagulation of macula
   2. Loss of central vision VA<20/200; Gun Barrel central visual field defect
7. Functional blindness – dx made only by ophthalmologist
   1. conversion d/o; optokinetic drum

Trauma

Lid laceration – close w/ 6 or 7-O nylon; consult ophthal if

1. lacrimal canaliculi
2. Levator muscle
3. Orbital septum
4. Canthal tendons
5. Lid margins

---

Traumatic Iritis – blunt trauma

• photophobia, dec VA, ciliary flush
• Slit lamp: cells & flares in AC
• IOP can be higher/lower
• Tx: short-acting cycloplegics / steroids

---

Hyphema – blunt trauma

• hemorrhage in AC; inc spontaneous with sickle cell
• Complication: Recurrent bleeding, extend to vitreous cavity, intractable glaucoma
• Tx – admit, HOB elevated 30o, Shield eye and ref to ophthal; ? ruptured globe
  • dilation to prevent iris movement
  • topical steroid help clot dissolution

---

Traumatic dislocated lens – blunt trauma

• Marfans’ – spontaneous;
• Iridodonesis – trembling of lens w/ head shaking
• Tx – Sx – can be delayed; C/I – secondary glaucoma

---

Corneal abrasions

• positive fluoresceine stain; ice rink sign – look for FB @ upper lid (invert to see)
• contact lens – risk of pseudomonas
• Tx:
  • topical cycloplegic
  • topical abx – pseudomonas coverage

Corneal FB

• rust ring from metallic FB
• remove w/ Burr / needle bevel using slit lamp & check seidel after removal
  • can wait 24-48hr when corena softens and rust ppt for easier removal
• Wooden splinters – must be removed using slit lamp
  • watch for fungal infection

---

Blowout fracture of orbit

• floor / medial wall easily subjected
• inferior rectus muscle & orbital fat may prolapse
  • entrapment of extra-ocular muscle: pain / diplopia in upward gaze
• infraorbital nerve may be involved – hypesthesia – infraorbital nerve
• Enophthalmos
• Dx – CT orbit
• Tx – Abx; sinus precaution (no nose blowing), ophthal consult
  • Sx (can be delayed) if persistent diplopia or poor cosmesis
  • earlier Sx in children – soft bony structure
• oculocardiac reflex – bradycardia, N/V, syncope

---

Vitrous and retinal hemorrhage

• blunt / penetrating trauma
• Loss of red reflex / retinal detail obsurbed / loss of vision

Retinal detachment

• inc risk in near-sighted individuals, hx of ocular Sx, trauma
• Painless vision loss; lowering / raising of curtain; flashing lights / floaters +/- RAPD
• Dx – ‘dunes on a beach’ retina; vitreous hemorrhage is suggestive
  • ocular us diagnostic
• Tx – emergent surgical treatment by ophthal

---

Orbital compartment syndrome

• acute elevation of IOP; mostly likely – retrobulbar hemorrhages
  • globe w/in bony orbit (closed space); globe may prolapse forward
  • medial & lateral canthal tendons fixated eyelids to orbital rim
• c/i: irreversible optic nerve damage, ischemic retinal damage w/in 90min
• Clinical dx: ocular pain, proptosis, RAPD, dec VA, inc IOP, chemosis, mydriasis, diminished retropulsion of globe, ophthalmoplegia (EOM)
• Tx: (within 1hr of injury & ocular dysfunction) immediate lateral canthotomy and cantholysis (IOP<30 if done right)
  • adjunct medical therapy; primary surgical intervention

---

3. For all patients with ocular complaints, measure and document visual acuity, then perform a detailed physical examination of the eye, including a slit lamp examination.

Ocular vital signs

1. Visual acuity
2. Pupil – RAPD
3. EOM
4. IOP – inc in acute angle closure glaucoma, hyphema, orbital compartment syndrome; low in globe rupture
5. Confrontational visual fields

Slit Lamp

1. Anterior eye
   1. cornea (fluoresceine) – abrasions, FB, lacerations (seidel sign – full thickness corneal injury – open globe)
   2. Anterior Chamber – iritis – cells and flares; hyphema, hypopyon

4. In patients with viral ocular infections, avoid routine prescription of topical steroids.

5. In patient presenting with a subconjunctival hemorrhage following trauma to the eye or orbital area, rule out the presence of a hyphema, including those that are diagnosed only on slit lamp examination.

Corneal laceration

• positive seidel sign with fluoresceine
• open globe injury – emergent referral to ophthal

Globe perforation

• penetrating wound of lid or teardrop pupil
• vitreous hemorrhage, 360 subconjunctival hemorrhage w/ chemosis, vision loss
• Dx – Seidel; CT orbit; emergency ophthal
• Tx – rigid metal eye shield, system abx, tetanus, NPO, ophthal

Intraocular FB – teardrop pupil; nonlocalizing pain;

• Inert – glass, plaster, rubber, silver, stone – may not be removed if asymptomatic
• Metallic – pounding metal
  • Dx – US / CT
• Wood, vegetable matter, iron, copper, steel
  • intense inflammation; remove immediately
• BBs & pellets (lead / iron)
  •  chorioretinitis – poorly tolerated
• Tx: surgical removal; NPO, tetanus, Eye shield, Abx to prevent endophthalmitis

---

 

Lid disorder

1. internal / external hordeolum / abscess of lid margin – often staph – painful
2. chalazion – chronic, nontender, SCC.
3. Pterygium – limbal lesion encroached onto cornea due to chronic UV
4. Pingueculum – raised conjunctival nodular degeration; doesn’t extend to cornea
5. Dacryosystitis – lacrimal sac inflammation, painful, swollen, red, medial unilateral mass – Tx systemic abx, ophthal f/u; can lead to orbital cellulitis
6. Dacryoadenitis – lacrimal gland inflammation; swelling, tenderness temporal / lateral aspect of upper eyelid (viral-mump, EBV, HSV, CMV); Tx cool compress / abx
7. Preseptal cellulitis – normal vision and EOM – dx CT; Tx abx, warm compress
8. orbital cellulitis – emergency – unilateral proptosis/chemosis/lid swelling + erythema, pain with EOM / globe retropulsion;
   1. Etiology – Ethmoid sinusitis / hematogenous <2yo
   2. may progress to meningitis / cavernous sinus thrombosis
   3. Dx CT
   4. Tx – IV abx; Surgery drainage prn ; admission