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

 

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