High Yield Topics

Red Eye

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Ovid: 5-Minute Sports Medicine Consult, The


Red Eye
Jeffrey R. Bytomski
William Felix-Rodriguez
Basics
  • Ocular inflammation
  • Dilation of the anterior ciliary arteries
  • Concomitant inflammation of the cornea, iris, or ciliary body
Description
  • Pain (especially on movement of the eye)
  • Blurred vision
  • Diplopia
  • Decreased visual acuity
  • Diminished visual fields
  • Photophobia
  • Floaters or flashes
  • Epiphora
  • Altered facial sensations
  • Anisocoria
  • Foreign-body sensation
  • Hyphema
  • Exophthalmos/enophthalmos
  • SC emphysema
  • Irregular-shaped pupil
Etiology
  • Canaliculitis:
    • Common pathogens are Actinomyces israelii, Candida, and Aspergillus.
    • It also may be iatrogenic, after instrumentation, or placement of silicone plugs in the treatment of dry eyes.
    • Redness and tenderness are most prominent at the side of the eye near the nose.
  • Conjunctivitis (viral, bacterial, or allergic):
    • Usually self-limited
    • Systemic manifestations depend on patient's status at presentation (age, immunocompromised state).
    • Obtain cultures and smear.
  • Blepharitis:
    • Usually self-limited
    • Seborrheic or staphylococcal infection
    • Mildly red eye (unilateral), slight discharge (clear)
    • Obtain cultures and smears.
  • Corneal injury:
    • Infective, toxic, degenerative, traumatic, or allergic
    • Assess for abrasions and visual acuity.
    • Ophthalmologic assessment within 48 hr of injury
  • Dacryocystitis:
    • Inflammation and/or obstruction of nasolacrimal duct
    • In children, Haemophilus influenzae
    • Adults: Staphylococcus aureus or β-hemolytic Streptococcus
    • Obtain cultures and smears.
  • Episcleritis:
    • Autoimmune/inflammatory systemic condition
    • Most often, unknown etiology
    • Inflammation well localized, not diffuse
    • Recurrence common
    • Corneal complications (15%) and uveitis (7%) (1)
  • Keratoconjunctivitis sicca:
    • Eye appears normal.
    • Deficiency of tear film components and lid surface
    • Epithelial abnormalities with autoimmune systemic disorders
    • Symptoms include itching, burning, irritation, and photophobia.
  • Narrow-angle glaucoma:
    • Pre-existing narrowing of the anterior chamber angle
    • Haloes around lights
    • Patients >50 yrs of age
    • Intraorbital pressure (IOP) is elevated (>21 mm Hg).
    • Nausea and vomiting common
    • Pupil mid-dilated and nonreactive to light
  • Scleritis:
    • Insidious decrease in vision
    • Globe tenderness
    • Swollen sclerae
    • Systemic disease (eg, rheumatoid arthritis, herpes-zoster ophthalmicus, gout) in 40% of cases (2)
    • Beware of the white eye; may be ischemic changes
  • Subconjunctival hemorrhage:
    • May occur spontaneously or with trauma
    • Flat, thin hemorrhage or a thicker collection of blood
  • Iritis:
    • Autoimmune/inflammatory systemic condition
    • Unknown etiology
    • Correlation of 50% with presence of HLA-B27 or HLA-B8 (3)
    • Trauma
    • Decreased visual acuity
    • Direct and consensual photophobia
    • Unilateral
  • Foreign body:
    • Detect evidence of corneal abrasion.
    • Penetration of the globe should be excluded.
    • Eversion of lid to exclude retained material
  • Iridodialysis:
    • Avulsion of a portion of the iris root in severe blunt trauma
    • Always associated with hyphema (manage as such)
    • Exclude retinal dialysis.
  • Orbital injury:
    • Fracture of orbital bones
    • Increased IOP
    • Intraorbital contents herniate/entrap through the fracture site.
    • Orbital floor and the medial wall are the most common fracture sites.
  • Hordeolum/chalazion:
    • Localized nodule at lid margin
    • Hordeolum: Staphylococcal infection of the glands of Zeis
    • Chalazion: Obstruction of the meibomian glands
Diagnosis
  • Visual acuity
  • Extraocular movements
  • Pupil reactivity
  • Pupil shape
  • Direct and consensual photophobia
  • Slit-lamp examination of the cornea for edema, defects, or opacification ± fluorescein
  • Anterior chamber evaluation for depth, cells, and flare
  • IOP measurements
  • Eyelid inspection with eversion
  • CT of the head/orbits for foreign bodies or orbital fractures
  • Culture/smears of purulent secretions; assess sexual history and potential contacts.
  • If recurrent and bilateral, search for autoimmune systemic conditions (CBC, ESR, ANA, purified protein derivative, angiotensin-converting enzyme levels, Lyme/cytomegalovirus titers)
  • Consult ophthalmologist for:
    • Dacryocystitis
    • Corneal ulcer
    • Scleritis
    • Angle-closure glaucoma
    • Uveitis
    • Proptosis
    • Orbital cellulitis
    • Vision loss
    • Uncertain diagnosis
History
  • Time and speed of onset
  • Ocular associations (eg, photophobia, blurry vision, discharge, etc.)
  • Systemic associations (eg, headaches, nausea, rash on the forehead)
  • Symptoms in the other eye, because a number of patients will fail to describe them if not asked
  • Specifically inquire about trauma.
  • Prior surgeries
  • Lazy eye (guide as to whether the recorded visual acuity is worrying or not)
  • Recently worn contact lenses
  • Ask about level of hygiene.
  • Ask if the patient forgot to take out daily disposable contact lenses.
  • Ask about prior similar episodes.
Physical Exam
  • Lids:
    • Note position with regard to contralateral eye.
    • Redness ± swelling
    • Lacerations (full thickness vs partial thickness, involvement of the puncta)
    • Note any skin abnormality, rashes, ill-defined thickening.
    • Note eyelashes.
    • Lid eversion

    • P.505


  • Lacrimal system: Look for swelling medial to the canthus and any evidence of redness, pain, or discharge.
  • Conjunctiva:
    • Look at color (injected, pale concretions or ulcerations).
    • Look for foreign bodies embedded up or down in the fornices.
  • Cornea:
    • Check if the patient is wearing contact lenses.
    • Look for corneal haziness.
    • Check for white dots visible before fluorescein staining (infiltrates suggestive of infective keratitis).
  • Anterior chamber:
    • Using a slit lamp; assess by narrowing the beam to 1 mm and putting it on its brightest light setting.
    • Angle it at 30–45 degrees to the cornea, and focus in past the cornea.
    • Look for cells (particles passing through the shaft of light) and flare (cloudiness).
  • Pupils:
    • Look at their relative sizes.
    • Elicit the red reflex in both eyes, and compare the size of these directly rather than shifting from one to the other close up.
    • Look for change in shape and any abnormal oscillations.
  • Visual acuity: Essential examination; should be carried out on every patient presenting with an eye problem.
  • Visual fields
  • IOP
  • Pupillary reactions:
    • Direct response to light
    • Light-near dissociation
Differential Diagnosis
  • Adult blepharitis
  • Chemical burns
  • Orbital cellulitis
  • Preseptal cellulitis
  • Chalazion
  • Acute hemorrhagic conjunctivitis
  • Allergic conjunctivitis
  • Bacterial conjunctivitis
  • Giant papillary conjunctivitis
  • Viral conjunctivitis
  • Contact lenses (complications)
  • Corneal abrasion
  • Dacryocystitis
  • Distichiasis
  • Ectropion
  • Dry-eye syndrome
  • Bacterial endophthalmitis
  • Entropion
  • Herpes simplex
  • Hordeolum
  • Pterygium
  • Acute angle-closure glaucoma
  • Episcleritis
Treatment
  • Canaliculitis:
    • Topical penicillins and cephalosporins
    • Surgery if not resolved with topical treatment
    • Obtain cultures and smears.
  • Conjunctivitis (viral, bacterial, or allergic): Topical treatment depending on etiology (antibiotics, antivirals, or antihistamines)
  • Blepharitis:
    • Treat with application of heat to warm the eyelid.
    • The eyelid margin is washed mechanically to remove adherent material.
    • Lid hygiene is essential. Apply warm compresses to closed lid 5–10 min twice daily 4 times a day.
    • Follow lid cleansing with topical antistaphylococcal treatment. Bacitracin or erythromycin ophthalmologic ointment is 1st line; apply to lids twice daily 4 times a day immediately after cleansing.
  • Dacryocystitis:
    • Treat with oral antibiotics (Augmentin).
    • Treat involvement with orbital cellulitis with IV antibiotics (Vancomycin).
  • Episcleritis: Self-limiting disease; no treatment needed
  • Corneal injury:
    • Topical antibiotics
    • Tetanus toxoid
  • Keratoconjunctivitis sicca:
    • Topical cyclosporine, artificial tears
    • Patch with lubrication at night.
    • Artificial tears insert in the mornings
    • Surgery for severe cases (ulceration, decreased visual acuity)
  • Narrow-angle glaucoma:
    • Topical α-adrenergic agonists, β-blockers, miotic agents, prostaglandin analogues, carbonic anhydrase inhibitors
    • Definitive treatment is laser iridotomy.
  • Scleritis: NSAIDs, glucocorticoids
  • Subconjunctival hemorrhage:
    • Self-limiting disease; no treatment needed
    • Treat with artificial tears
  • Iritis: Topical steroids and cycloplegics
  • Foreign body:
    • Removal; topical antibiotic drops and cycloplegics
    • Avoid removal if penetration to cornea >25%.
  • Iridodialysis: Observation and bed rest
  • Orbital injury: Rapid surgical intervention if a significant fracture is present, with possible herniation of intraorbital contents
  • Hordeolum/chalazion: Warm compresses and topical antibiotics
In-Patient Considerations
Initial Stabilization
N/A
Admission Criteria
  • Endophthalmitis
  • Perforated corneal ulcers
  • Orbital cellulitis
Discharge Criteria
Depends on the diagnosis: If the diagnosis is certain and visual loss will not result, the patient may be discharged without consultation.
References
1. Red Eye Evaluation: Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine. Coauthor(s): Gregory I Mazarin, MD, Assistant Professor, Department of Emergency Medicine, Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine; Consulting Staff, St Vincent's Midtown, North Shore University Hospital Updated 2006.
2. Wilhelmus KR. The red eye. Infectious conjunctivitis, keratitis, endophthalmitis, and periocular cellulitis. Infect Dis Clin North Am. 1988;2:99–116. Review.
3. Nishimoto JY. Iritis. How to recognize and manage a potentially sight-threatening disease. Postgrad Med. 1996;99:255–257, 261–262. Review.
Additional Reading
Bertolini J, Pelucio M. The red eye. Emerg Med Clin North Am. 1995;13:561–579.
Cullom R, Chang B. The Wills eye manual: office and emergency room diagnosis and treatment of eye disease. 2nd ed. Philadelphia: JB Lippincott, 1994.
Juang PS, Rosen P. Ocular examination techniques for the emergency department. J Emerg Med. 1997;15:793–810.
Subconjunctival Hemorrhage: Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona Coauthor(s): Vivian Monsanto, MD, Consulting Staff, The Mackool Eye Institute and Laser Center; Norvin Perez, MD, Clinical Assistant Professor of Emergency Medicine, Albert Einstein College of Medicine; Consulting Staff, Department of Emergency Medicine, Montefiore Medical Center Updated 2007.
Codes
ICD9
379.93 Redness or discharge of eye


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