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Resident Rounds

Resident Rounds. By: Warren Whitsitt September 17 2014. Case. 45 year old Male comes in to AHC. 1 day of his eyes looking like this. Immediate Differential. Questions To Ask?. Physical Exam?. Imaging? Labs? Tests?. Evaluation of the RED EYE. Warren Whitsitt September 17 2014.

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Resident Rounds

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  1. Resident Rounds By: Warren Whitsitt September 17 2014

  2. Case • 45 year old Male comes in to AHC. • 1 day of his eyes looking like this

  3. Immediate Differential

  4. Questions To Ask?

  5. Physical Exam?

  6. Imaging? Labs? Tests?

  7. Evaluation of the RED EYE Warren Whitsitt September 17 2014

  8. Objectives • Develop a differential diagnosis • Develop a standard set of questions to triage presentations • Review physical exam techniques relative to an Eye Exam • Review scenarios when we need to refer to Opthomology

  9. Some different presentations of RED EYE

  10. Lets Review Some Eye Anatomy

  11. Differential of a RED EYE The Red Eye – NEJM 2000 Non-Urgent/Emergent Stye (Hordeolum) Chalazion Conjunctivitis Subconjuctival Hemorrhage Corneal Abrasion* Corneal Foriegn Body* Contact Lens Overwear* *Urgent follow-up if not better in 24-48 hours -Some controversy between sources of when/if corneal involvement is emergent (Uptodatevs NEJM) Urgent/Emergent Infectious Keratitis Iritis Acute Angle Glaucoma Hyphema Hypopyon

  12. The Key Triage Questions Your on QFHT call and phone by a patient who says their eyes are red. What do you ask?? • Some Standard Questions • How long? • One or both eyes? • -Eye pain? • -Fevers, or other Symptoms? • -Sick Contacts? But what questions MUST you ask every patient??

  13. 1. Is Vision Affected? Can you read ordinary print with the affected eye(s)? If Vision is affected in the setting of a Red Eye?? SERIOUS. Needs to be seen right away! Why? Vision is affected in Infectious Keratitis Iritis Acute Angle Glaucoma ALL URGENT/EMERGENT If Vision is not affected? -Normal Acuity is generally a reassuring sign.

  14. 2. Is There a Foreign Body Sensation? Objective Signs -Patient is unable to spontaneously open the eye or keep it open Subjective Signs -Scratchy Feeling -Grittiness -”Sand in my eyes” • Objective Foreign Body Sensation indicates corneal involvement • Subjective Foreign Body Sensation may be seen in allergy, viral conjunctivitis, or dry eyes. Does not necessarily mean corneal involvement Corneal Process/Involvement -Infectious Keratitis – EMERGENT! -Corneal Abrasion -Actual Foreign Body

  15. 3. Is The Photophobia? Sensitivity to light Indicates a corneal process or iritis!! -Patient may be wearing a hat or sunglasses -May keep their head down -May sit turned away from lights and windows -May have turned off the lights while waiting for you

  16. 4. Was There Trauma? Increased suspicion for sub-conjunctival hemorrhage or globe rupture

  17. 5. Do you wear contact lenses? Increased suspicion of bacterial keratitis

  18. 6. Is there discharge, other than tears, that continues throughout the day?? -Patients usually interpret morning crusting as pus – whether it is actually pus or not. -Morning crusting can occur with both watery discharge or purulent discharge Therefore, the more important question is what type of discharge they are having throughout the day Watery Discharge -Allergy -Stye -Viral Conjunctivitis -Allergic Conjunctivitis -Dry Eyes Opaque Discharge -Bacterial Conjunctivitis -Bacterial Keratitis(Emergent!)

  19. Ophthalmologic Examination GOOD NEWS: The fundus examination is typically not helpful in the ddx of a red eye. Why? -If dx is a lid or conjunctival process – Fundus will not show pathology -If dx is an iritis or keratitis, - The pupil will be very small and the patient photophobic making the exam very difficult -If the dx is Acute-close glaucoma - Though the pupil can be dilated, the exam is very difficult d/t corneal edema from the high intraocular pressure The other signs/symptoms and exams are better, easier, and more reliable

  20. Measurement of Visual Acuity • Good Standard is using the Snellen chart at 20 feet. • However it is not important to determine the exact acuity of the vision (20/30, 20/40), but rather to document visual acuity in crude categories Normal reading vision?? (Ask pt to read something at their normal distance) Normal form vision?? (Ask pt to count your fingers) Light Perception?? MUST TEST ACUITY BEFORE LIGHTS ARE SHINED INTO THE EYE OR DROPS ARE APPLIED

  21. Remember?? 1. Is Vision Affected? Can you read ordinary print with the affected eye(s)? If Vision is affected in the setting of a Red Eye?? SERIOUS. Needs to be seen right away! Why? Vision is affected in Infectious Keratitis Iritis Acute Angle Glaucoma ALL URGENT/EMERGENT If Vision is not affected? -Normal Acuity is generally a reassuring sign.

  22. Penlight Exam – Does the pupil react? • Pupil is fixed and usually mid-dilation in angle-closure glaucoma

  23. Is The Pupil Very Small? (1-2mm) • Pinpoint pupils seen in: -Corneal Abrasions • Infectious Keratitis • -Iritis

  24. What is the pattern of redness? • Diffuse Injection (dilated blood vessels) involving conjunctiva (bulbar and palpebral) • - Conjunctiva Problem • -Ciliary Flush (Injection marked at the limbus) • - Infectious Keratitis, • -Iritis, • -Angle Closure Glaucoma • -Hemorrhagic rather than injection • - Subconjunctival hemorrhage

  25. Is there a white spot, opacity, or foreign body on the cornea? • White Spot • - Bacterial Keratitis • -Grayish branching opacity • - Herpes Simplex Keratitis • -Foreign Body • - Corneal Foreign Body • What will stain with Fluorescein Dye? • Corneal Abrasion • White spot • Grayish Branching Spot • A corneal foreign body will NOT pick up stain

  26. Is there hyopyon or hyphema? • Hypopion (White cells in the anterior chamber) • - Infectious Keratitis • - Endopthalmitis • -Hyphema (Blood in anterior chamber) • - Blunt or penetrating trauma

  27. Review- Important Questions • History • Is vision affected • -Is there a foreign body • -Is there photophobia • -Was there trauma • -Are you a contact lens wearer • -Is there discharge, other than tears, that continues throughout the day • Exam • Visual Acuity • -Does the pupil react to light • -Is the pupil very small • -What is the pattern of redness • -Is there a white spot, opacity, or foreign body on the cornea • -Is there hypopion or hyphema

  28. Review Small Pupil Diffuse Injection Ciliary Flush Affected Vision Photophobia Small pupil Iritis

  29. Review Ciliary Flush Affected Acuity Headache Hard Eye Acute Angle Glaucoma

  30. Review Normal Acuity No Photophobia No foreign body Discharge throughout the day Normal pupil Normal Cornea Diffuse Injection Conjunctivitis

  31. Review Diffuse Injection Opacity Affected Acuity Photophobia Foreign body Sensation Contact Lenses Small Pupil Hypopion Bacterial Keratitis

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