Transcript The Red Eye - Calgary Emergency Medicine

EM Rounds
Colleen Carey, BA, MD, CCFP (EM)
July 31, 2008
Thanks to Dr. Jean Chuo, UBC Ophthalmology
Resident
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Hx
Exam
Most common etiologies
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Traumatic versus atraumatic
Diagnosis
Treatment
When to get help
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Trauma
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Consider unrecognized trauma- awoke with
symptoms
Pain? Itch? FB sensation?
Visual acuity changes, halos
Contact lenses- ? Overwear
Sick contacts/Viral symptoms
Prior surgery or eye disorders
Systemic disease
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Visual acuity
Visual fields
Pupil shape and reactivity
Lid closure
Foreign bodies
Ciliary flare
Foggy cornea (edema)
Corneal infiltrate
Fluorescein- corneal defects, Sidel’s sign
Anterior chamber cells
Intraocular pressure
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Projectile metallic FB
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Rust ring
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Get orbital Xray
Visual axis involved?- refer if unable to completely
remove
Burr
Tetanus status
Antibiotic prophylaxis?
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Get help if
not healing
 corneal ulcer
 large surface area
 infringing on visual axis
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Usually due to blunt trauma and immediate
Gross: layers out
Microscopic: cells in anterior chamber
Always refer
Tx: cycloplegics, steroids, serial IOP monitoring, sleep
sitting upright, avoid valsalva, avoid anticoagulants,
hard shield, avoid exertion
Complications:
 Iritis
 Synechiae, glaucoma
 Rebleeding
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Penetrating FB
Blunt trauma by an object smaller than a fist
Blunt trauma with an orbital fracture
Prior open globe surgery
All must be repaired to prevent sympathetic
ophthalmia
Need a hard shield.
Emergency referral, poor prognosis
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Red, painful, decreased vision
Anterior chamber cells+/- hypopion
Almost exclusively post-surgical complication
Rare: 1:100,000 cataract surgeries
Urgent referral
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Very common problem
Mild itch, dry, gritty sandpaper sensation
Many causes:
Contact lens overwear
 Dry Calgary air
 Preservatives, antibiotic eye drops
 Incomplete lid closure
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Rule out other problems
Discontinue cause, moisturize, follow up in ER
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Allergic
Viral
Bacterial
Irritative
Treat bacterial conjunctivitis with
flouroquinolone or erythromycin drops.
Treat allergic with antihistamines, nasal steroid
spray, allergen avoidance, cromolyn drops
Refer any keratitis
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Short fat
branches with
bulbs
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HSV keratitis
Dendritic fluoroscein enhancing lesion
 Hypoesthetic cornea
 +/- periocular HSV vesicles
• Tx is acyclovir +/- viroptic drops
• HSV can affect any part of the eye
• Next day referral as long as Tx started
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Long thin tapered branches
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HHV 3 (VZV)
V1 (opthalmic branch of CN V)
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Macular rash =>vesicular lesions
Conjunctivitis
Keratitis
Uveitis/iritis +/- retinal necrosis
Cranial nerve palsies 3,4,6
Cxns: Chronic ocular inflammation, vision loss,
neuralgia, late corneal sequelae
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Risk Fx:Family Hx, contralateral eye,
hyperopia, Asian race, age
Hx: Sudden eye pain, photophobia, halos
PE: Shallow anterior chamber, iris bombe,
middilated pupil, hazy cornea, elevated IOP
Tx: one drop each of: 0.5% timolol 1%,
apraclonidine, and 2% pilocarpine. Oral
acetazolamide, IV mannitol
Ensure pressure drops within an hour
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Complete occlusion of the anterior
chamber angle by iris tissue
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Causes:
Infections, eye disorders, systemic disorders
Trauma, autoimmune disorders, VZV, lyme
disease, leukemia/lymphoma, idiopathic
Photophobia and dull ache
Urgent referral to ophtho
Get baseline IOP and start Predforte drops and
cycloplegics
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Intense injection at limbus
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Causes
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Presentation
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Valsalva
Coagulopathy
Visual acuity
Absence of pain
Absence of photophobia
Absence of discharge
Should resorb in 1-2 weeks
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And that is the problem.
Alkali chemical burn- large corneal epithelial
defect and scleral ischemia.
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Of all the conditions you have seen today, this
is the fastest to destroy an eye, and can have
the worst prognosis
You have only minutes to diagnose and irrigate
Morgan lens, many litres
Afterward:confirm pH, slit lamp exam for
corneal defect, r/o deposits in conjunctival
recesses.
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Insidious onset
Consider retro-orbital causes: mass, aneurysm.
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Chronic recurrent eyelid inflammation
Staph aureus or seborrhea (pityrosporum)
Warm lid compresses
Topical antibiotic eyedrops+/- ointment
Dandruff shampoos to scalp to eradicate
pityrosporum
Slow response
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Hordeolum- acute, painful
Chalzion- chronic, non painful
Hot compresses, milking
Refer if not resolving for I+C
Chronic lesions- ? Biopsy to r/o CA
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Note irregular corneal light reflex