evaluation of the painful red eye 04.17.2015

8/20/2019 Evaluation of the Painful Red Eye 04.17.2015

1/17

Morning Report4/17/15

Erin Bennett, MD/MPH


2/17

History of Present Illness

• 12 year old female presents it! left eye redness for 2 ee"s t!at !as

orsened

• Eye pain it! snee#ing, yaning, a"ing $p, and general eye mo%ement

• Bl$rry %ision, !eada&!es, and r$nny nose

• 'ears glasses ($t not &onta&ts

• )at!er !as also !ad some re&ent eye pain and redness

•

*een in t!e P+H ER and pres&ri(ed polymiin eye drops - 1 ee" ago

• R.* Positi%e for eye p!otop!o(ia, pain, redness, (l$rry %ision,

!eada&!e, r!inorr!ea


3/17

History

• Medi&al History – 0(normal gait it! intoeing

– .(esity

– anglion &yst in rist s/p remo%al

• )amily History – )at!er it! eye pain and redness 4 days3 randmot!er it!

&atara&ts3

• *o&ial History – i%es it! mom, dad and sister3 *!e is in 7 t! grade3

• Medi&ations – Polymiintrimet!oprim drops to left eye 6 days

• 0llergies Ra((its, 8D0


4/17

.(9e&ti%e• :itals ;


5/17

$ssessment%

12 year old femaleit!

• left eye redness

• P!otop!o(ia

• pain it! eyemo%ements

• (l$rry %ision

• for 2 ee"s it!orsening symptoms


6/17

Dierential Diagnosis

• la$&oma

• +atara&ts

• %eitis/Irido&y&litis

• Hyp!ema

• Hypopyon

• 0nterior %eitis irido&y&litisF

• Posterior %eitis &!oroiditisF

• 8eratitis

– oninfe&tio$s

– Infe&tio$s

• Ba&terial

• :iral

• .r(ital &ell$litis

• Perior(ital &ell$litis

• Intrao&$lar lymp!oma

• Epis&leritis/s&leritis

• )oreign (ody

• +on9$n&ti%itis

– Ba&terial

–

:iral – 0llergi&

• +orneal a(rasion

• +orneal $l&er

• Endop!t!almitis

• Blep!aritis

•

Da&ro&ystitis• Da&ryoadenitis

• *$(&on9$n&ti%al !emorr!age

• :itreo$s !emorr!age


7/17

Initial E%al$ation

• Eye Eam – Eyelids, &on9$n&ti%ate, s&lerae, p$pils

• +ranial er%e eam – + III o&$lomotorF Inner%ates t!e p$pil p$pillary lig!t

rea&tionF, le%ator palpe(rae s$perioris, medial, s$perior, andinferior re&ti, and inferior o(liA$e

– + I: tro&!learF inner%ates t!e s$perior o(liA$e

– + :I a(d$&ensF inner%ates lateral re&t$s

• :is$al 0&$ity ;est – .D 2>/2>

– .* 2>/6>

– . 2>/4>


8/17

Initial E%al$ation

•

*lit amp

• Dilated f$nd$s eam ormal

Right Left

ids/as!es ormal ormal

+on9$n&ti%ae/*&lerae '!ite/G$iet


9/17

Evaluation ofthe Painful, RedEye • Pertinent &istory

– 'as t!ere tra$maJ

– Is %ision ae&tedJ

– Is t!ere foreign (ody sensationJ

– Is t!ere p!otop!o(iaJ

– Does t!e patient ear &onta&t lensesJ

– Is t!ere dis&!argeJ

– 0re t!eir systemi& signs/symptoms eg fe%erFJ

•Pertinent Physical E'am – 0ssess %is$al a&$ity

– Inspe&t or(it, lids, las!es, &on9$n&ti%a

– 0ssess etrao&$lar mo%ements

– +!e&" p$pillary response

– Inspe&t anterior &!am(er it! penlig!t

– E%ert lid

– +onsider $ores&ein eam

– +onsider diagnosti& trial of topi&al anest!eti&

Red (lags)"ndicationsfor

"mmediate Referral• De&reased %is$al a&$ity

• neA$al p$pils/irreg$lar

p$pil• +orneal

edema/$l&er/erosion

• Blood or p$s in anterior&!am(er

• R$pt$red glo(e

• Pain not relie%ed (y topi&al

anest!eti&s and/orasso&iated it!na$sea/%omiting

• 0&id/al"ali ($rn


10/17


11/17

Location *isual $cuity (oreign bodysensation

Photophobia +ischarge linical(eatures

-reat)Refer

ornea

0(rasion l/ 'atery History/tra$ma,$ores&ein

;reat

+orneal l&er l/ 'atery ImmediateReferral

+onta&t lenso%erear

l/ 'atery History ;reat $nlesserosion/$l&er

)oreign Body l/ 'atery History 0ttemptremo%al refer

+!emi&al ($rn l/ 'atery History Immediatereferral

Ba&terial "eratitis l/ M$&op$r$lent '!ite spot on&ornea /

$roes&ein

Immediatereferral

:iral 8eratitis l/ 'atery )l$ores&eingray/(ran&!ing

dendrite

Immediatereferral

: 8eratitis l/ 'atery History Immediatereferral

$nterior hamber

Iritis l/

K one/atery Mioti&/irreg$larp$pil Immediatereferral

Hyp!ema l/ K one/atery Blood layer inanterior&!am(er

Immediatereferral

Hypopyon l/ K / one/p$r$lent P$s layer inanterior&!am(er

Immediatereferral

+ongenital

la$&oma

l/ K / one/atery )ied, mid

dilate& p$pil,&lo$dy &ornea

Immediate

referral

lobe


12/17

0nterior %eitis

•+lini&al Manifestations – nilateral/(ilateral eryt!ema, &iliary $s!, irreg$lar p$pil, iris ad!esions,

pain, p!otop!o(ia, small p$pil, poor %ision, ptosis appearan&e

– ran$lomato$s %s3 ongran$lomato$s• ran$lomato$s grainy s$rfa&e persistent inammation

• Nongranulomatous/ a&$te onset, pain, intense lig!t sensiti%ity, %iral infe&tions, 0I

diseases

• DeCnitions – %eitis Inammation of t!e $%ea/middle portion of eye

• 0nterior Iris +iliary (ody

• Posterior +!oroid

– 0nterior %eitis presen&e of le$"o&ytes in t!e anterior &!am(er of t!eeye on slit lamp• e$"o&ytes are not normally fo$nd (eteen t!e &ornea L lens

• Dilated &iliary %essels, &ells in aA$eo$s !$mo$r, "eratin pre&ipitates on posteriors$rfa&e of &ornea, ad!esion of iris to &ornea, inammatory &ells in t!e %itreo$s

&a%ity


13/17


14/17

• Infe&tio$s +a$ses – H*:, Herpes oster,

+M:, ;ooplasmosis,*yp!ilis, ;B, +ats&rat&!, 'est ile

• Dr$gs/Hypersensiti%ity Rea&tions –

Rifa($tan, +idofo%ir,)l$oroA$inolones,Bisp!op!onates

•*ystemi&Imm$ne/Inammatory +a$ses – NR0, Reiter

*yndrome,*ar&oidosis, Be!&etdisease,Inammatory Boel

Disease, M*,*pondyloart!ritis,Psoriati& art!ritis

0nterior %eitis +a$ses


15/17

• ;opi&al l$&o&orti&oids Prednisolone 1@ &y&lopentolate

gtt

• *ystemi& treatment if resistant oral gl$&o&orti&oidsF

• *ome people reA$ire imm$nos$ppressi%e agents

a#at!ioprine, my&op!enolate, met!otreate, &y&losporineF

;reatment


16/17

Prognosis

• :aries (ased on etiology and se%erity

• )or neonset, loer rate of

medi&ationfree remission and

persistent inammation

– NI0, Be!&etOs, Bilateral $%eitis, !/o&atara&ts, 1 or greater %itreo$s &ells or%is$al a&$ity of 2>/2>> or orse


17/17

Referen&es

• elsonOs Essentials of Pediatri&s =t! Edition

• PREP *elf0ssessment Pediatri&s and Ed$&ation Program

• !ttps//$ptodate&om3e#proy3li(3$ta!3ed$/&ontents/e%al$ationoft!e

redeyeJ

so$r&esear&!Qres$ltLsear&!eyepainandrednessLsele&ted;itle1@

7E15>

evaluation of the painful red eye 04.17.2015

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