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
- Conjunctivitis
- Bacterial – purulent discharge on lids/lashes
- topical Abx
- Gonococcal – copious purulent, pre-aucicular adenopathy
- neonates 3-5 d post SVD
- Detected by culture
- Tx IV / IM cefuroxime / ceftriaxone, NS wash of eye, Full septic w/u
- Chlamydia – trachoma – pre-auricular adenopathy + conjunctival lymphoid follicles
- neonate 5-14d post SVD + otitis, PNA
- Detected by culture
- Tx topical erythromycin, IV tetracycline for 2-3 wk
- Viral – adenovirus, pre-auricular adenopathy, URI. serous/clear discharge
- complication: EKC – Epidemic Keratoconjunctivitis: ophthal, topical abx
- Allergic – cobblestone papillae under upper lid
- itching, tearing, stringy discharge
- Tx – cool compress, topical antihistamine
- Chemical – don’t neutralize acid/alkali by a buffer (heat causes damage)
- Alkali burn – EMERGENCY – liquefaction necrosis / rapid penetration
- immediate tap water & continuous saline irrigation up to 24hr – RL 500ml/30min; Goal pH 7-7.4 but irrigate till symptoms improve
- Acid burn – coagulation necrosis
- RL irrigation
- Alkali burn – EMERGENCY – liquefaction necrosis / rapid penetration
- Bacterial – purulent discharge on lids/lashes
- Corneal inflammation / infection
- HSV – dendritic patter; Tx – oral & topical antiviral
- HZV – CN5, tip of nose (Hutchinson’s); pseudodendrite – ophthal consult to r/o retina involvement; Tx – ophthal consult; oral antiviral
- Corneal ulcer – bacterial/viral/fungal/chemical/Vit A deficiency
- painful, white flocculent cornea infiltrate
- +/- hypopyon
- Contact lens – pseudomonas
- topical fluoroquinolone / C&S / Imm ophthal consult
- UV keratitis – corneal flash burn “diffuse punctate keratopathy”
- Welder’s keratitis, snow blindness, tanning beds
- delayed symptoms, tearing, blurred, intense pain
- topical / oral anesthesia; prophylactic abx
- Endophthalmitis – intraocular
- endogenous – baceteria/endocarditis
- Exogenous – eye Sx, intraocular FB
- Hypopyon – dec vision, floaters, pain, red
- Tx – ophthal – Intravitreal abx / vitrectomy + IV Abx
- Iritis / Uvea
- iritis – anterior uveitis; cyclitis – intermediate uveitis; choroiditis – posterior uveitis
- Risk factors: trauma, infection (Lyme), autoimmune
- Decreased VA, consensual photophobia, ciliary flush
- Slit lamp: cells +/- flares in anterior chamber
- Tx: cycloplegics / topical steroids / mydriatics – cyclopentolate; ophthal consult
- c/i: posterior synechiae – iris adhere to lens; anterior synechiae – iris adhere to cornea (can lead to glaucoma)
- Acute angle closure glaucoma
- IOP>30, steamy cornea, mid-dilated nonreactive pupil, n/v/headache
- Tx: definitive – peripheral iridotomy
- Timolol 0.5% drop (BB), alphaclonidine drop (alpha agonist) – reduce humor production
- Acetazolamide 500mg Iv/po x 1 to dec humor volume
- Pilocarpine 1% (cholinergic) Q15min (when IOP <40) to improve outflow
- Mannitol 2ml/kg IV
- Scleritis – painful, autoimmune
- Anterior – diffuse, nodular, necrotizing
- posterior – complicated w/ retinal detachment, acute angle closure glaucoma
- Tx steroids
- Episcleritis (contains small vessels – thin tissue between conjunctiva / sclera)
- 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
- CRAO – true emergency
- sudden painless vision loss; thrombosis / thromboembolic, vasculitis/spasm
- RAPD (normal in amaurosis fugax), pale retina with pink dot near fovea (cheery-red macula)
- Tx – digital massage of anterior globe, Acetazolamide 500mg IV, Timolol 0.5%, carbogen / hyperbaric Ox / ophthal consult
- Temporal arteritis – elderly >50
- headache, visual complaints, malaise, myalgia, wt loss, jaw claudication
- temporal artery tenderness/pulseless, swelling of optic nerve +/- RAPD
- Dx – ESR>100/CRP high; made by temporal artery biopsy
- Tx – IV methylprednisolone & ophthal consult
- CRVO
- sudden painless vision loss / fundus – blood and thunder – no Tx
- Optic neuritis – demyelinating inflammation of optic nerve
- loss of central vision + eye pain with EOM
- unilateral optic disc swelling; RAPD
- cause: MS
- Dx: clinical dx; MRI brain/orbit to assess demyelinating lesion
- Tx: IV steroids
- Papilledema
- optic nerve swelling due to inc ICP
- Loss of vision; headache / N / V
- cause: HTN, ICB, intracranial mass; Idiopathic intracranial HTN
- Dx – bilateral papilledema; CT/MRI brain; LP to measure ICP
- Solar retinopathy
- photocoagulation of macula
- Loss of central vision VA<20/200; Gun Barrel central visual field defect
- Functional blindness – dx made only by ophthalmologist
- conversion d/o; optokinetic drum
Trauma
Lid laceration – close w/ 6 or 7-O nylon; consult ophthal if
- lacrimal canaliculi
- Levator muscle
- Orbital septum
- Canthal tendons
- 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
- Visual acuity
- Pupil – RAPD
- EOM
- IOP – inc in acute angle closure glaucoma, hyphema, orbital compartment syndrome; low in globe rupture
- Confrontational visual fields
Slit Lamp
- Anterior eye
- cornea (fluoresceine) – abrasions, FB, lacerations (seidel sign – full thickness corneal injury – open globe)
- 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
- internal / external hordeolum / abscess of lid margin – often staph – painful
- chalazion – chronic, nontender, SCC.
- Pterygium – limbal lesion encroached onto cornea due to chronic UV
- Pingueculum – raised conjunctival nodular degeration; doesn’t extend to cornea
- Dacryosystitis – lacrimal sac inflammation, painful, swollen, red, medial unilateral mass – Tx systemic abx, ophthal f/u; can lead to orbital cellulitis
- Dacryoadenitis – lacrimal gland inflammation; swelling, tenderness temporal / lateral aspect of upper eyelid (viral-mump, EBV, HSV, CMV); Tx cool compress / abx
- Preseptal cellulitis – normal vision and EOM – dx CT; Tx abx, warm compress
- orbital cellulitis – emergency – unilateral proptosis/chemosis/lid swelling + erythema, pain with EOM / globe retropulsion;
- Etiology – Ethmoid sinusitis / hematogenous <2yo
- may progress to meningitis / cavernous sinus thrombosis
- Dx CT
- Tx – IV abx; Surgery drainage prn ; admission
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