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CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
Chapter 19 – Red and Painful Eye
NOTE: CONTENT CONTAINED IN THIS DOCUMENT IS TAKEN FROM ROSEN’S EMERGENCY MEDICINE 9th Ed.
Italicized text is quoted directly from Rosen’s.
Key Concepts:
1. Critical diagnoses, such as caustic injury, orbital compartment syndrome, and acute angle closure glaucoma, require immediate treatment and ophthalmology consultation.
2. Prompt and prolonged irrigation is advised for patients who experience caustic injury to the eye.
3. Headache and nausea may be prominent symptoms in acute angle-closure glaucoma.4. Complete abolition of a foreign body sensation after instillation of local anesthesia
solution indicates a high likelihood of a superficial corneal lesion.5. 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.
6. A localized corneal defect with edematous, inflammatory changes may signal corneal ulceration.
7. A corneal dendritic pattern may signal a herpetic infection, which can progress to corneal opacification and visual loss.
8. 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.
9. Conjunctivitis is usually self-limited and rarely requires antibiotic treatment
Rosen’s in Perspective
Ocular 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.
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
Reference the text, run through the flashcards, listen to the podcast, rinse, and repeat. Spaced repetition is key!
Core Questions:
1. Detail the pertinent points to review when taking the history of a patient presenting with a red and painful eye - Box 19.2
2. Outline an approach to the ocular physical examination - Box 19.33. Outline the components of the slit lamp examination - Box 19.4 4. What signs and symptoms, if present, likely indicate the presence of serious ocular
pathologies - Box 19.15. What is a relative afferent pupillary defect and what conditions cause it?6. List ten causes of increased intraocular pressure7. List five causes for an absent red reflex - Box 19.58. Name three critical, emergent, urgent, and non-urgent causes of the red and painful
eye? - Figure 19.8
Wisecracks:
1. What are the fundoscopic findings of a central retinal artery occlusion?2. What is the pinhole test and what visual disturbances does it correct?3. What are the three most common causes of an irregularly shaped pupil?4. 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 19.2
Of 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 trauma- Determine whether or not any exposure to caustic substances or irritants brought about
the patient’s symptoms- Characterize the pain, paying particular attention to the following:
- PQRSTU features- Provocative/palliative factors
- Determining if opening/closing the eyes exacerbates the pain is key
- Understanding the effects of bright light or dark settings on the pain is important
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
- Quality of pain- Itching tends to be more associated with
blepharitis/conjunctivitis/dry eye syndrome- Burning is often associated with episcleritis, limbic
keratoconjunctivitis and superficial irritation of the pterygium or pingueculae
- Sharp pain is generally indicative of pathology in the anterior chamber
- Dull pain is often associated with increased intraocular pressure - Radiation of pain to adjacent anatomic structures- Severity- Timing- Patient’s understanding of pain
- Presence or absence of a foreign body sensation- The presence of a foreign body sensation is a strong indicator of corneal damage
or injury- Presence of lid swelling, tearing, discharge, crusting- Sensation of light sensitivity- Use of contact lenses
- Type- How often are they cleaned- How often is the lens solution changed
- Use of corrective lenses- When was their last assessment- Has there been any subjective change in vision despite use of corrective lenses
- History of ocular surgery- History of systemic diseases that may affect the eye- Medications that the patient is taking- Presence of any known or suspected allergies
[2] Outline an approach to the ocular physical examination - Box 19.3
Complete Eye Examination
● Visual Acuity○ Use the best possible score using their corrective lenses
● Visual Fields○ Done via using confrontation method
● External Examination○ Globe position in orbit○ Conjugate gaze○ Periorbital soft tissues, bones, and sensation
● Extraocular Muscle Movement
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
● Pupillary Evaluation○ Direct ○ Indirect○ Swinging Light Test
● Pressure Determination○ Multiple devices available for testing
● Slit-lamp Examination● Fundoscopic Examination
[3] Outline the components of the slit lamp examination - Box 19.4
Slit Lamp Examination
● Lids and Lashes○ Inspected for blepharitis, lid abscess (ex. hordeolum) and internal or external
pointing, and dacrocystitis ● Conjunctiva and sclera
○ Inspected for punctures, lacerations, and inflammatory patterns● Cornea (with and without fluorescein)
○ Evaluated for abrasions, ulcers, edema, foreign bodies, or other abnormalities● Anterior chamber
○ Evaluated 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 noted
● Iris○ Inspected for tears or spiraling muscle fibers noted in acute angle-closure
glaucoma● Lens
○ Examined for position, general clarity, opacities, and foreign bodies
[4] What signs and symptoms, if present, likely indicate the presence of serious ocular pathologies - Box 19.1
Pivotal Findings More Likely Associated With a Serious Diagnosis in Patients with a Red or Painful Eye
● Severe ocular pain● Persistently blurred vision● Exophthalmos (proptosis)● Reduced ocular light reflection● Corneal epithelial defect or opacity● Limbal injection (also known as “ciliary flush”)● Pupil unreactive to a direct light stimulus● Wearer of soft contact lenses
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
● Neonate● Immunocompromised state● Worsening 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:
1. Vitreous hemorrhage2. Retinal detachment3. Retinal ischemia4. Optic neuritis
[6] List ten causes of increase intraocular pressure
This in no way is a comprehensive list, but should give you some accolades on your next off-service ophthalmology rotation:
1. Acute angle-closure glaucoma2. Open-angle glaucoma3. Vitreous hemorrhage4. Orbital cellulitis/abscess5. Retrobulbar hemorrhage6. Hyphema7. Iritis with hypopyon
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
8. Chronic steroid eye drop use9. Enopthalmitis 10. Incorrect measurement technique11. Ocular malignancy12. Vomiting13. Ocular trauma
[7] List five causes for an absent red reflex - Box 19.5
Causes of Inability to Visualize a Red Reflex or the Optic Fundus
● Opacification of the cornea, most commonly by edema secondary to injury or infection● Hyphema or hypopyon within the anterior chamber● Extremely miotic pupil● Cataract of the lens● Blood in the vitreous or posterior eye wall● Retinal detachment
[8] Name three critical, emergent, urgent, and non-urgent causes of the red and painful eye and describe their treatment? - Figure 19.8
Potential Diagnosis
Management Consultation Disposition
Caustic Kerato-
conjunctivitis
Immediate and copious irrigation with tap water or
sterile normal saline until tear-film pH = 7
Solids - lift particles out with dry swabs before irrigation
For acidic exposures, minimum irrigation volume is 2L over 20
minutes
For alkali exposures, minimum irrigation volume is 4L over 40
minutes
Consult 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 treatment
May discharge only if tear film pH
= 7 and no findings on examination
except conjunctival
injection, ophthalmologist can reevaluate
next day
Orbital Compartment
Syndrome
Measure IOP unless possibility of ruptured globe; IOP > 30
mmHg may require emergent
IOP > 20 mmHg may be a surgical
emergency, may add
Admit all cases of retrobulbar
pathology causing
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
(OCS) needle aspiration or lateral canthotomy and cantholysis in
ED
medications used in glaucoma to decrease
IOP before decompression in the
ED
Obtain axial CT of brain and axial and coronal
CT of the orbits/sinuses
increased IOP. Others might be candidates for
discharge depending on the
cause of the problem.
Retrobulbar Hematoma
Correct any coagulopathy or thrombocytopenia
See OCS See OCS
Retrobulbar Emphysema
Antibiotic coverage to prophylactically cover sinus
flora
See OCS See OCS
Retrobulbar Abscess
Antibiotics (as in the case of orbital cellulitis below)
See OCS See OCS
Scleral Perforation
Protect eye from further pressure, provide pain relief,
and prevent vomiting
Parenteral antibiotics and tetanus prophylaxis
Ophthalmologist must come to ED if there is any concern for globe
penetration
Admit for continuation of antibiotics and
possible procedural intervention
Hyphema First rule out open globe
May require ultrasound if cannot visualize posterior
structures
Measure IOP unless possibility of open globe
IOP > 30 mmHg may require acute treatment as in
glaucoma; if IOP > 20 mmHg and no iridodialysis, may use
cycloplegic to prevent iris motion
Discuss findings and use of aminocaproic
acid and steroids, other medical therapy, best disposition, and follow up examination by an
ophthalmologist within 2 days
Some patients may be admitted for
observation, bed rest, head elevation,
frequent medication administration
Most patients can be discharged
with careful instructions to return for any
increased pain or change in vision
Patients should decrease physical activity and sleep with an eye shield
in place
Eyes should be left open when
awake s that any change in vision
can be immediately recognized
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
PO NSAIDs for analgesia
Sub-conjunctival Hemorrhage
Exclude coagulopathy or thrombocytopenia if indicated
by history
None required if no concerns for underlying ocular pathology and no
acute complications
Reassure patient that discoloration
should resolve over 2 to 3 weeks
Corneal Perforation
Protect eye from further pressure, provide pain relief,
and prevent vomiting
Parenteral antibiotic and tetanus prophylaxis required
Ophthalmologist must come to the ED
Admit for continuation of antibiotics and
procedural intervention
Ruptured Globe
Protect eye from further pressure, provide pain relief,
and prevent vomiting
Parenteral antibiotic and tetanus prophylaxis required
Ophthalmologist must come to the ED
Admit for continuation of antibiotics and
procedural intervention
Corneal Abrasion
Antibiotic prophylaxis with polymyxin-B/trimethoprim
solution 1 drop every 3 hours while awake and erythromycin
ointment while sleeping
Discuss plan for follow-up in 1 to 3 days
May discharge if no other findings.
No patch.
Traumatic Mydriasis
None once other abnormalities of the eye, cranial nerves, and brain have been reasonably
excluded
Discuss plan for follow up evaluation of slowly developing hyphema and ensure resolution
May discharge if no other findings
Inflammatory Pseudotumor
Evaluate IOP, evaluate for DM and vasculitis with CBC, basic metabolic panel, UA, and CRP
or ESR
Obtain axial CT of brain and axial and coronal CT of orbits
and sinuses
IOP >20 mmHg may be surgical emergency, may add medications used in glaucoma to decrease IOP before decompression in ED
May 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 days
Orbital Cellulitis
Measure IOP and rule out orbital compartment syndrome
IOP >20 mmHg may be surgical emergency, may add medications
Admit all cases of orbital cellulitis
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
Start parenteral antibiotics with second generation
cephalosporin or with ampicillin/sulbactam to cover
skin and sinus flora
used in glaucoma to decrease IOP before decompression in ED
Obtain blood cultures and start antibiotics
Axial and coronal CT of orbits and sinuses to
rule out FB, retrobulbar abscess, orbital gas,
subperiosteal abscess, osteomyelitis, and
changes in cavernous sinus
Consider LP
Periorbital Cellulitis
First rule out orbital cellulitis
PO antibiotics for sinus and skin flora if not admitting
Ophthalmologist may admit if systemically ill,
case in moderate or severe, or no social support for patient
May discharge mild cases with PO antibiotics
Ophthalmologist must reevaluate
next day to ensure no orbital
extension
Dacryo-cystitis and
Dacryo-adenitis
First rule out orbital cellulitis and periorbital cellulitis
Inspect for obstruction of punctum by SLE, may express
pus by pressing on sac, PO antibiotics for nasal and skin
flora if not admitting
Ophthalmologist may admit if systemically ill, in case of moderate or
severe, or no social support for patient
Ask about culturing before prescribing
medications if admitting, and then may add medications used
in glaucoma to decrease IOP before
decompression
May discharge mild cases with PO analgesics and antibiotics
Apply warm compresses to eyelids for 15 minutes and
gently massage inner canthal area four times a day
Orbital Tumor Measure IOP
Evaluate for extraocular signs of malignancy
Obtain axial CT of brain and axial and coronal CT of orbits
IOP > 20 mmHg may be a surgical
emergency, prescribe to decrease IOP in ED
Ophthalmologist may want MRI, MRA, or
Based on findings and discussion with consultant
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
and sinuses orbital ultrasonography
Hordeolum External - warm compresses often all that is needed, may
prescribe anti-Staphylococcus ointment BID
Internal - PO antibiotics for beta-lactamase Staphylococcus
Outpatient referral only for treatment failure
after two weeks
Discharge with instructions to apply warm
compresses to eyelids for 15
minutes four times daily and gently
massage abscess four times daily
Blepharitis None, except artificial tears for dry eye
Outpatient referral only for treatment failure
after two weeks
Discharge 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
daily
Chalazion None Outpatient referral only for treatment failure
after two weeks
Discharge with instructions to apply warm
compresses to eyelids for 15 minutes QID,
gently massage nodules QID
Acute Angle-Closure
Glaucoma
Administer medications below in ED if IOP >30 mmHg
Reduce humor volume:-Timolol 0.5% 1 drop
-Apraclonidine 1%, 1 drop q8hr-Dorzolamide 2% 1 drops, if
SCD or trait then methazolamide 50 mg PO
Decrease inflammation:-Prednisolone 1%, 1 drop q 15
min x 4
Discuss any IOP >20 mmHg with
Ophthalmologist
Based on findings and discussion with consultant, which primarily
depends on speed of onset
and response to treatment
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Constrict pupil:-Pilocarpine 1%-2% 1 drop
after IOP <50, repeat in 15 min
Consider osmotic gradient:-Mannitol 2g/kg IV
Keratitis (abrasion or UV Injury)
First, rule out corneal penetration either grossly or
employing Seidel’s test
Relieve blepharospasm with topical anesthetic
Inspect all conjunctival recesses and superficial
cornea for any foreign material that can be removed by
irrigation or manually lifted from surface
Ophthalmologist must come to the ED if there is any concern for globe rupture or penetration.
Otherwise, consult for follow up examination in
1-2 days
Discharge if not infected or ulcerated
May provide topical antibiotics using polymyxin B with bacitracin or
trimethoprim
Erythromycin, gentamycin, and
sulfacetamide are less desirable single-agents
PO NSAIDs or narcotics
No patch
Keratitis (ulceration)
Relieve pain and blepharospasm with topical
anesthetic
Staph/Strep species still most common, but Pseudomonas
greater percentage in existing infections (especially contact lens wearer), so prescription with topical fluoroquinolone is
preferred
Discuss with Ophthalmologist any
potential need to debride or culture
before starting antibiotic
Based on findings and discussion with consultant
Topical 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
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
visual axis or large need
fortified antibiotics (tobramycin)
Keratitis (herpetic infection)
Relieve pain and blepharospasm with topical
anesthetic
Prescribe acyclovir 3% ointment, trifluridine 1%
solution, or vidarabine ointment
VCV and CMV not normally given antivirals if
immunocompetent
Discuss with Ophthalmologist any
potential need to debride or culture
before starting antiviral
Based on findings and discussion with consultant
Typical vidarabine or acyclovir
dosing is five times daily for 7 days, then taper
over 2 weeks
Typically trifluridine dosing is 1 drop every 2 hours for 7 days, then taper over 2
more weeks
PO NSAID’s or narcotics for
analgesia
No patch
Scleritis Decrease inflammation with PO NSAIDs
Discuss findings and use of topical or PO
steroids
May discharge patient with medications
recommended by ophthalmologist
and ensure reevaluation in 2-
3 days
Anterior Uveitis and Hypopyon
First rule out glaucoma with IOP measurement
Prescribe in ED if IOP > 20 mmHg
Otherwise 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 day
Patients with hypopyon are
generally admitted
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
Endophthal-mitis
Empirical parenteral antibiotic with vancomycin and
ceftazidime to cover Bacillus, Enterococcus, or Staph
Ciprofloxacin or levofloxacin when others contraindicated
Ophthalmologist must admit for parenteral and
possibly intravitreal antibiotics
Admit all cases of endophthalmitis
Kerato-conjunctivitis
Treat for conjunctivitis by likely etiologic category
Discuss findings and use of prednisolone
acetate 1% (frequency determined by
ophthalmologist
May discharge patient with medications
recommended by consultant, ensure reevaluation in 2-
3 days
Episcleritis Relieve irritation with artificial tears and decrease
inflammation with ketorolac drops
Outpatient referral only for treatment failure in 2
weeks
May discharge patient with PO
NSAIDs +/- topical ketorolac
Inflamed Pinguecula
Decrease inflammation with naphazoline or ketorolac drops
Outpatient referral only for treatment failure
after 2 weeks
Discharge to follow-up with
Ophthalmologist for possible
steroid therapy or surgical removal
Inflamed Pterygium
Bacterial Conjunctivitis
Topical polymyxin-B/trimethoprim in
infants and children, because more Staph
Topical sulfacetamide or gentamycin clinically effective in 90% of uncomplicated adult
cases.
Topical fluoroquinolone if Pseudomonas possible
Culture drainage and Ophthalmology consult
in all neonates and those at risk for vision
loss or systemic sepsis
Neisseria gonorrhoeae can be rapidly sight-
threatening
Discharge uncomplicated cases within 10 days of topical
antibiotics bilaterally
regardless of infection laterality
Use ointments in infants and drops
in others
Chlamydia Conjunctivitis
Empirical PO azithromycin
Consider empirical parenteral ceftriaxone for concurrent N.
gonorrhoeae
Culture drainage and consult in all neonates
and those at risk for vision loss and systemic sepsis
Discharge uncomplicated
cases on 5 days of PO
azithromycin
Contact Dermato-
conjunctivitis
Irrigation with tap water or sterile normal saline
Outpatient referral only for severe cases or
treatment failure after 2
Identify offending agent and avoid
subsequent
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
Decrease irritation with naphazoline drops
weeks exposure. Discharge
uncomplicated cases on
naphazoline
Toxic Conjunctivitis
Allergic Conjunctivitis
Decrease irritation with naphazoline drops
Outpatient referral only for severe cases or
treatment failure after 2 weeks
Identify antigen
Consider treating other allergic
symptoms with PO antihistamines
Viral Conjunctivitis
Decrease irritation with naphazoline drops, or
ketorolac drops
Culture drainage, consult Ophthalmology
in all neonates and those at risk for vision
loss or systemic sepsis
Ask about pregnant mothers,
infants, and immunocompromised individuals in
close contact
Discharge uncomplicated
cases with instructions on respiratory and direct-contact
contagion for 2 weeks
Wisecracks:
[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:
1. General pallor of the retina2. Attenuation of the retinal arteries3. Attenuation of the retinal veins
CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast
[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:
1. Blunt or penetrating trauma2. Previous surgery3. Synechiae 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.