The Red Eye and Ocular Emergencies

Shafaf A. Shahruddin August 2011

Anatomy of the Eye

www.jaapa.com

Eye Exam
Visual acuity - Snellen eye chart, counting fingers, light perception CN II VII - Pupils, visual fields, EOMs, facial droop Inspection/palpation of eye and surrounding structures Asymmetry, proptosis, enophthalmos, orbital rim Lids/ducts Slit lamp Anterior segment Fundoscopy Posterior segment Contraindications to dilation significant head trauma, suspected rupture, history of glaucoma Intraocular pressure - Goldman applanation tonometry, Tonopen

Anterior Segment
Perform at slit lamp
If not available, use ophthalmoscope

Inspect
Conjunctiva Cornea Anterior chamber Iris Lens

Estimating Anterior Chamber Depth

Posterior Segment
Examine Vitreous Optic disc Retinal vessels Macula

Tonometry
Measures the intraocular pressure by calculating the force required to depress the cornea a given amount with a tonometer.

IOP 10-20 is considered normal.

In chronic open angle glaucoma, IOP can be 2030, and in acute angle closure glaucoma, IOP can be greater than 40.

The Swinging Flashlight Test

Measures both the direct and consensual response of pupil to light. Step 1: Shine light in right eye. This will cause BOTH right and left pupils to constrict via CN III through Edinger-Westphal nucleus. Step 2: Then swing pen light to left eye and check to make sure the left eye CONSTRICTS. If it constricts, this means that the LEFT CN II is intact and is causing a direct pupillary reflex. If it dilates, then this is a sign that the LEFT retina or optic nerve is damaged and is called an Afferent pupillary defect. (APD)

The Red Eye

HISTORY
Blurring of vision- duration, severity Pain- important symptom Headache Haloes Photophobia Trauma- chemical injury, blunt injury Discharge watery, purulent, copious Contact with similar illness

EXAMINATION
Visual acuity Congestion- diffuse, sectoral,circumcorneal Cornea-clear, hazy Anterior chamber- hypopyon, hyphema Pupil- middilated, irregular Lens - ? Mature cataract

Algorithm for Diagnosing Red Eye

Key worrisome clinical findings (ophthal referral needed):
Pain: Pain in eye often indicates more serious intraocular pathology (iritis, glaucoma). Visual acuity: if decreased, usually more serious cause. Pupil: if sluggish, worry about acute glaucoma Pattern of redness: CILIARY FLUSH (Redness worse near cornea, usually serious intraocular cause: iritis or glaucoma).

Ciliary Flush
Injection of deep conjunctival vessels and episcleral vessels surrounding the cornea. Seen in iritis (inflammation in the anterior chamber) or acute glaucoma. NOT seen in simple conjunctivitis

Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

Red Eye: Key historical questions

DO YOU HAVE PAIN? Biggest distinguishing factor between emergent and non-emergent Do you wear contacts? (increased risk of keratitiscorneal infection) Do you have any associated symptoms?
Decreased vision photophobia/diplopia flashes/floaters Halos/N/V/Abd pain Any above require referral

STRUCTURES THAT CAN CAUSE A RED EYE

Conjunctiva Episclera Sclera Cornea Iris

Unilateral more potential to be dangerous Bilateral allergic, infective

Main differential of red eye:

Main differential of red eye:
Conjunctivitis (infectious/noninfectious) Trauma, Foreign body Subconjunctival hemorrhage Angle closure glaucoma Iritis/uveitis Kerititis Scleritis, episcleritis

SIGHT THREATENING
Corneal ulcer Acute Uveitis Acute Glaucoma Hyphema Exposure keratopathy Endophthalmitis Scleritis Orbital cellulitis

NON SIGHT THREATENING

Spontaneous subconjunctival haemorrhage Viral conjunctivitis Bacterial conjunctivitis( except gonococcal that can cause corneal perforation) Allergic conjunctivitis Episcleritis

RED FLAGS!!
Sudden, severe pain and vomiting Zoster skin rash Decreased visual acuity Corneal crater Branching, dendritic corneal lesion Ocular pressure > 40 Failure to blanch with phenylephrine

INFECTION CAUSE
Conjunctivitis Orbital cellulitis Dacrocystitis Keratitis Corneal ulcer

CONJUNCTIVA :Conjunctivitis
Inflammed : blood vessels dilated and apparent thorough clinical history and examination Ophthalmologist consulted if infection suspected or vision impaired or fails to respond to therapy in 3-4 days

Causes
Major causes: virus, bacteria, allergies, tear deficiency associated symptom important Pattern: diffuse vs. ciliary

tender pre-auricular lymphnode: contagious viral conjunctivitis

QUESTIONS TO ASK
One or both eyes? How long? What sort of discomfort? Vision affected? Any discharge?

Conjunctivitis : Discharge
Discharge
Purulent
Clear Stringy, white mucous

Cause
Bacteria
Viruses Allergies

Treatment
Gutt artificial tears
Topical antibiotics if necessary

Topical ointments for children

If no improvement in 4 days - refer to Ophthalmologist

Viral conjunctivitis
Self-limited no specific treatment indicated may last for weeks, usually 10-14 days If pain, photophobia or decreased vision- refer

Viral conjunctivitis
Watery discharge
highly contagious palpable pre-auricular lymph node

URTI, sore throat, fever: common

BACTERIAL CONJUNCTIVITIS
Red Eye with uniform engorgement of all the conjunctival blood vessels. presence of a yellow-white mucopurulent discharge. Eyes may be difficult to open in the morning, glued together by discharge. usually bilateral (but often sequential

Gonococcal conjunctivitis
Swollen lids,purulent exudate,beefy-red conjunctiva and conjunctival oedema

gonococcal organism can penetrate intact corneal epithelium

producing ulceration and perforation if treatment delayed URGENT ophthalmological referral

Screen mother and partner

GONOCOCCAL CONJUNCTIVITIS

URGENT
-Needs admission -Urgent swab for gram stain and culture - Eye toilet -Intensive topical antibiotics - Systemic antibiotics

Allergic conjunctivitis
Lid or conjunctival oedema associated with a watery discharge and white, stringy mucous itching predominant Sx

sometimes with burning

Allergic conjunctivitis
Associated conditions: hay fever, asthma, eczema Contact allergy: chemicals,cosmetics Treatment: topical antihistamines, tears to relieve itching

Refer refractory cases

ALLERGIC CONJUNCTIVITIS

-Itchiness and watery discharge -Relapse and remits -Papillae on conjunctiva -Associated with asthma, eczema -Needs long term treatment with topical mast cell stabilisers or topical antihistamines -BEWARE OF LONG TERM STEROID USE

ORBIT : CELLULITIS
diffuse,erythematous oedema of lids
tender to touch

preorbital /preseptal cellulitis: VA, pupils

and motility - normal with no proptosis treatment:
systemic antibiotics warm compresses

ORBITAL CELLULITIS
True medical emergency Vision and life-threatening potential

Prompt consultation with Ophthalmologist

SYMPTOMS
Redness and swelling of the eyes and eyelids A/w URTI

Signs
Red,swollen lids and conjunctiva periorbital area: relatively uninflammed ocular motility: impaired with pain on eye movements proptosis optic nerve involvement : decreased vision, RAPD, optic disc oedema

Management
Hospitalization Stat eye consultation

Blood culture
Orbital / brain CT scan ENT referral if necessary

Treatment
IV antibiotics stat : Staphylococcus, Streptococcus, H. influenzae Surgical debridement if fungus, no improvement or subperiosteal abscess Complications: cavernous sinus thrombosis, meningitis

LACRIMAL SYSTEMS: Dacryocystitis

Congenital or acquired obstruction of NLD

persistent tearing and occasional discharge

doesnt respond to antibiotics red eye sometimes lacrimal sac swollen/inflammed secondary infection

Treatment : Congenital
Massage tear sac daily Probing, irrigation if chronic Systemic antibiotics if infected

Viral keratitis
Primary Herpes simplex infection:
unilateral/bilateral blepharoconjunctivitis watery discharge enlarged pre-auricular nodes skin vesicles on lids access to CNS-trigeminal ganglia: dormant

Corneal involvement
usually unilateral
red & tearing eye Corneal sensation single/multiple dendrites stained with fluorescein --> refer to Ophthalmologist

Herpes zoster ophthalmicus -Vesicular rash in the V1 cranial nerve

distribution

Herpetic keratitis -branching dendrite

Bacterial keratitis/corneal ulcer

red and painful eye purulent discharge corneal opacity may be seen decreased vision

EMERGENCY referral to Ophthalmologist

STEROID SIDE-EFFECTS
Primary care physician should avoid prescribing topical ophthalmic steroids or antibiotic-steroid combination cornea and anterior segment

Side Effects
Facilitates corneal penetration of herpes virusscarring and perforation Elevate IOP (steroid induced glaucoma) Potentiate fungal corneal ulcers

INFLAMMATION CAUSE
Episcleritis Scleritis Iritis Blephritis

Episcleritis / Scleritis
Inflammatory conditions with redness and pain/tenderness
localized but may be diffuse often idiopathic but may be a/w rheumatoid arthritis and other autoimmune disorders

needs referral to Ophthalmologist for differentiation and management

Scleritis

Nodular scleritis

Episcleritis

Nodular scleritis

Scleritis sight threatening

Episcleritis non sight threatening

ANTERIOR UVEITIS

Iritis

Circumcorneal redness pain photophobia decreased vision miotic pupil

Causes:
systemic inflammatory conditions like infections, arthritis, sarcoidosis, urethritis,bowel disorders Trauma

LID MARGIN : BLEPHARITIS

Chronic inflammation of lid margin Types: Staphylococcal,seborrheic, or a combination of both Symptoms: foreign body sensation, burning, mattering

Treatment
Proper lid hygiene :
warm compresses cleansing with non-irritating shampoo

Antibiotic ointment

Oral antibiotics: refractory cases

Acute angle closure glaucoma

outflow of AH from anterior chamber is suddenly blocked in susceptible individuals Signs: Eye : red Pupil : mid-dilated and oval Cornea: cloudy

IOP : higher Usually ONE eye only

1. Acute Angle Closure Glaucoma (AACG) Diagnosis

History: Acute onset, higher risk in farsighted Symptoms:

Pain Halos (around lights) Visual loss (usually peripheral) Nausea/vomiting Conjunctival injection Corneal edema Mid-dilated, fixed pupil IOP (normal: 10 20 mmHg)

Signs:

www.eyemd.com

Glaucoma - Pathophysiology
Aqueous humor produced by ciliary body, enters ant. chamber, drains via trabecular meshwork at angle to enter canal of Schlemm In AACG, iris obstructs trabecular meshwork by closing off angle Optic nerve damage 2 IOP

www.eyesearch.com

Acute Angle Closure Glaucoma

Medical Tx
Reduce production of aqueous humor Topical -blocker (timolol 0.5% - 1- 2 gtt) Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po) Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min) Or increase outflow Topical -agonist (phenylephrine 1 gtt) Miotics (pilocarpine 1-2%) Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then Q1H

Definitive Tx
Ophtho referral: Laser peripheral iridectomy

References

Rodriquez J. Prevention and Treatment of Common Eye Injuries In Sports. American Family Physician. April 2003. http://eyelearn.med.utoronto.ca/default.htm www.cgi.ualberta.ca http://www.opt.pacificu.edu/ce/catalog/10310-SD/Triage.html Bashour, Mounir. Corneal Foreign Body. www.emedicine.com. Accessed: November 8, 2007. Goodall, KL et al. Lateral canthotomy and inferior cantholysis: an effective method of urgent orbital decompression for sight threatening acute retrobulbar hemorrhage. Injury 1999 30(7): 485-90. Leibowitz HM. The red eye. N Engl J Med. 2000 Aug 3;343(5):345-51. Melsaether, Cheri. Ocular Burns. www.emedicine.com. Accessed: November 9, 2007. Pokhrel, Prabhat K, et al. Ocular Emergencies. American Family Physician. 2007 Sep 15; 76(6). Vernon, Steven Andrew. Differential Diagnosis in Ophthalmology: Chapter 5. McGraw Hill: 1999. Wiler, Jennifer. Diagnosis: Orbital Blowout Fracture. Emergency Medicine News. 2007 Jan. 29(1) p 33.

Ocular Injury
i. ii. iii. Eye protection : Lid and lashes. Bony orbit. Retrobulbar fat.

Ocular Injury
Causes; Motor vehicle accident Work related injury Burns Sports and recreation

Ocular Injury(classification)
A. Non penetrating (blunt injury). B. Penetrating. C. Chemical injury. D. Burns (thermal injury).

Coup-counter coup mechanism

Non penetrating injury

Caused by a blunt object. A. Subconjunctival hemorrhage. C/F : -bright red appearance localized to one area. - margin well defined - If distal margin not identified, AC shallow, globe soft beware of globe rupture (posterior rupture)

Subconjunctival Hemorrhage

Rx : -reassurance, condition will resolved within 10 14 days.

Non penetrating injury

B. Conjunctiva/corneal foreign body. -metallic -non-metallic. C/F : -foreign body sensation -tearing, pain, redness blurring of vision

3. Foreign body
Often metallic foreign body following work injury. Signs and symptoms: foreign body sensation, tearing, red, or painful eye. Pain often relieved with the instillation of anesthetic drops. Stain with fluorescein stain and illuminate under blue fluorescent light (Woods lamp) is effective to see corneal epithelial defects.

Linear epithelial defects suggestive of foreign body under the eye lid

Corneal Foreign Body

Treatment
Apply topical anesthetic Remove foreign body with sterile irrigating solution or moistened sterile cotton swab Never use needle Apply antibiotic ointment 24-hour follow-up is mandatory Refer if foreign body cannot be removed

Non penetrating injury

Mx : -examine the anterior segment, evert the eyelids. -remove the FB under LA -irrigate the eye if still feeling discomfort

Non penetrating injury

C. Abrasion -eyelid -cornea ( most common ) -conjunctiva C/F: -pain/F.B sensation -tearing /redness -photophobia/blurring of vision

Fluorescein Stain

5. Corneal injuries
Abrasions, lacerations, ulcers Symptoms: extreme eye pain, relieved with lidocaine drops. Visual acuity usually decreased, depending on location of injury in relation to visual axis. Inflammation leading to corneal edema can decrease VA. Diagnosis: fluorescein staining to see epithelial defect. Seidels test for aqueous leakage to diagnose laceration.

Corneal injuries
Seidels test: Concentrated fluorescein is dark orange but turns bright green under blue light after dilution. This indicates aqueous leakage which is diluting the green dye.

Non penetrating injury

Rx:
-Pad the eye with antibiotic ointment - Lubricants with antibiotic cover for infected cases

Non penetrating injury

D. Contusion C/F : -proptosis. -swelling of the eyelids -subconj.hemorrhage -chemosis

Non penetrating injury

D. Contusion C/F : -hyphema a)level b)diffuse

Non penetrating injury

E: Retinal haemorrhage

F. Commotio retinae No treatment needed, condition will resolve within weeks to months

Non penetrating injury

G. Choroidal rupture - whitish circumscribed streaks in the fundus. H. Retinal detachment - ass. with retinal break/tear. - well demarcated red area in retina.

NON-PENETRATING EYE INJURY I. Injuries of the bony orbit a) Orbital rim fracture -due to direct impact to the face -eg: Dashboard or steering wheel during a car crash

Non-Penetrating injury
J. Blow out fracture. -caused by an impact to the front of the eye -eg: clenced fist, baseball, dashboard -c/f : pain diplopia limited eye movement paraesthesia ( skin of the lower eyelid & cheek)

4. Orbital Blowout Fracture

Signs & Sxs:
Enophthalmos Diplopia Impairment of eye movement 20 to EOM entrapment, orbital hemorrhage or nerve damage Orbital emphysema Infraorbital n. anesthesia

CT should include axial and coronal cuts

Orbital blowout fracture

Disposition - If no diplopia, minimal displacement, and no muscle entrapment, discharge with ophthalmology follow up within a week. Surgery - For enophthalmos, muscle entrapment, or visual loss. Management: Ice packs beginning in clinic/ED and for 48 hrs will help decrease swelling associated with injury. Elevate head of bed (decrease swelling). If sinuses have been injured, give prophylactic antibiotics and instruct patient not to blow nose. Treat nausea/vomiting with antiemetics.

Non-Penetrating injury
K. Medial wall fracture -C/o; eye pain, redness double vision CSF rhinorrhea epistaxis -CF: subcutaneous emphysema Limitation of adduction

Penetrating injury
A. Laceration - caused by sharp object. I) Laceration without prolapse of the eye tissue. - c/f : pain, redness, tearing reduce in vision

Penetrating injury
A. Laceration II) Laceration with prolapse of the eye tissue. - intraocular content seen - eg. Prolapse of the iris or vitreous through the laceration.

Penetrating injury
B. Intraocular Foreign Body - cause by high velocity injury -eg. Explosion, machinery, power tools, hammering - c/f : pain, redness sudden loss of vision. h/o object get into the eye.

Penetrating injury
B. Intraocular Foreign Body -o/e: small corneal/scleral wound at point of entry. FB lodged within the eye -eg. Iris lens vitroeus retina

What Do You Do?

1. Stabilize hook 2. Brief exam to document visual acuity, pupillary responses, visual fields 3. Protect eye from further damage 4. NPO, Tetanus, IV Abx 5. Pain control, antiemetics 6. Send to Ophtho!

Chemical injury
Type of chemical : a) Acid b) Alkaline a) b) c) Classification : Mild injury. Moderate injury. Severe injury.

Chemical injury
C/F :pain watery redness photophobia blurring of vision O/E: eye redness corneal abrasion corneal haziness (depending on severity)

Chemical injury
Mx : -check pH -put LA to the affected eye -irrigate the eye continuously for 30mins- 1 hour (sterile solution) -cleaned the fornices -avoid direct pressure on the globe -refer eye MO stat

Chemical injury
Sequele: -corneal opacity -corneal vascularization -severe dry eyes

Burns
Exposed to : a) Ultraviolet radiation b) Electric welding c) Short circuit in high voltage line d) Infrared exposure e) Viewing sun without filter esp. at the time of the suns eclipse. f) Hallucinogenic drug eg. LSD. g) Radiation eg. X-ray. h) Nuclear devices.

Burns
C/F : pain redness watery photophobic blurring of vision Mx : - antibiotic eye drop/ointment. - Refer to eye MO

TRAUMA CAUSE
Hyphema

Subconjunctiva haemorhage

TRAUMA

Carotid cavernous fistula -corkscrew vessels

Chemical injury
A true ocular emergency Require immediate irrigation with nearest source of water Management depends on offending agent

Management
ALKALI
Immediate irrigation URGENT referral to Ophthalmologist

ACID
Immediate irrigation Management as corneal abrasion Referral to Ophthalmologist

OTHERS COMMON CASES SEEN

Hordoleum Chalazion Pterygium

LIDS: HORDEOLUM
Glands surrounding lash follicles obstructed--> hordeolum/ stye

LIDS : CHALAZION
Meibomian gland secreting oily component of tears arranged longitudinally drain posterior to eyelash line on lid margin obstructed--> chalazion

Hordeolum (Sty)

Chalazion

TREATMENT
Goal:
to promote drainage

Treatment:
acute / subacute: warm compresses TDS chronic: refer to an Ophthalmologist

CORNEA : PTERYGIUM
Extension of this process onto cornea wing-like structure typically on nasal side of

cornea
red when vascularizes and inflammed when

exposed to irritants in air such as smoke

Pterygium

MANAGEMENT
Artificial tears Vasoconstrictors to reduce redness When inflammation severe or pterygium actively

growing - refer
Excision : high recurrence rateGoal:
to promote drainage

Treatment:
acute / subacute: warm compresses TDS chronic: refer to an Ophthalmologist

VISION-THREATENING RED EYE SIGNS/SYMPTOMS : REFERRAL REQUIRED

Decreased vision Ocular pain Photophobia Circumcorneal redness Corneal oedema Corneal ulcers/dendrites Abnormal pupil Proptosis Elevated IOP

VISION-THREATENING RED EYE DISORDERS : URGENT REFERRAL

Orbital cellulitis Chemical injury Corneal infection Hyphaema

Iritis
Acute glaucoma

2. Retinal detachment
Pathophysiology: separation of neurosensory layer of retina from underlying choroid and retinal pigment epithelium.

Schaffers sign Presence of vitreous pigment Useful in that it has a NPV of 99% for detachment.

Retinal detachment
Risk factors
Increasing age History of posterior vitreous detachment Myopia (nearsightedness) Trauma Diabetic retinopathy FHx of RD Cataract surgery. black curtain coming down over visual field bright flashes of light (photopsia) increasing floaters decreased visual acuity distortion of objects (metamorphopsia) +APD on exam.

Signs and symptoms

Retinal detachment
Diagnosis - If direct ophthalmoscopy is inconclusive, refer to ophtho for dilated fundus exam with indirect ophthalmoscope. Direct ophthalmoscopy is not very effective at visualizing periphery where most RDs occur. Treatment
Surgery to replace retina onto nourishing underlying layers. Surgical options include laser photocoagulation therapy, and scleral buckle with intraocular gas bubble to keep retina in place while it heals.

KEY MANAGEMENT POINT- know classic presentation so you can refer to an ophthalmologist quickly.

Chemosis

Pinguecula

Herpes Simplex Kerititis