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The Red Eye

The Red Eye. EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident. Goals. Hx Exam Most common etiologies Traumatic versus atraumatic Diagnosis Treatment When to get help. History. Trauma

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The Red Eye

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  1. The Red Eye EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident

  2. Goals • Hx • Exam • Most common etiologies • Traumatic versus atraumatic • Diagnosis • Treatment • When to get help

  3. History • Trauma • Consider unrecognized trauma- awoke with symptoms • Pain? Itch? FB sensation? • Visual acuity changes, halos • Contact lenses- ? Overwear • Sick contacts/Viral symptoms • Prior surgery or eye disorders • Systemic disease

  4. Red eye exam • Visual acuity • Visual fields • Pupil shape and reactivity • Lid closure • Foreign bodies • Ciliary flare • Foggy cornea (edema) • Corneal infiltrate • Fluorescein- corneal defects, Sidel’s sign • Anterior chamber cells • Intraocular pressure

  5. Foreign body • Projectile metallic FB • Get orbital Xray • Rust ring • Visual axis involved?- refer if unable to completely remove • Burr • Tetanus status • Antibiotic prophylaxis?

  6. Corneal abrasion • Get help if • not healing • corneal ulcer • large surface area • infringing on visual axis

  7. What is this?

  8. Hyphema • Usually due to blunt trauma and immediate • Gross: layers out • Microscopic: cells in anterior chamber • Always refer • Tx: cycloplegics, steroids, serial IOP monitoring, sleep sitting upright, avoid valsalva, avoid anticoagulants, hard shield, avoid exertion • Complications: • Iritis • Synechiae, glaucoma • Rebleeding

  9. What is this?

  10. Globe rupture • Penetrating FB • Blunt trauma by an object smaller than a fist • Blunt trauma with an orbital fracture • Prior open globe surgery • All must be repaired to prevent sympathetic ophthalmia • Need a hard shield. • Emergency referral, poor prognosis

  11. A bad day of fishing

  12. Endophthalmitis • Red, painful, decreased vision • Anterior chamber cells+/- hypopion • Almost exclusively post-surgical complication • Rare: 1:100,000 cataract surgeries • Urgent referral

  13. What is this?

  14. What is this?

  15. Superficial punctate keratitis • Very common problem • Mild itch, dry, gritty sandpaper sensation • Many causes: • Contact lens overwear • Dry Calgary air • Preservatives, antibiotic eye drops • Incomplete lid closure • Rule out other problems • Discontinue cause, moisturize, follow up in ER

  16. Is this SPK?

  17. Conjunctivitis/keratoconjunctivitis • Allergic • Viral • Bacterial • Irritative • Treat bacterial conjunctivitis with flouroquinolone or erythromycin drops. • Treat allergic with antihistamines, nasal steroid spray, allergen avoidance, cromolyn drops • Refer any keratitis

  18. What is this?

  19. What is this?

  20. What is this? • Short fat branches with bulbs

  21. Herpes Simplex Virus • HSV keratitis • Dendriticfluoroscein enhancing lesion • Hypoesthetic cornea • +/- periocular HSV vesicles • Tx is acyclovir +/- viroptic drops • HSV can affect any part of the eye • Next day referral as long as Tx started

  22. What is this? • Long thin tapered branches

  23. Herpes Zoster Ophthalmicus • HHV 3 (VZV) • V1 (opthalmic branch of CN V) • Macular rash =>vesicular lesions • Conjunctivitis • Keratitis • Uveitis/iritis +/- retinal necrosis • Cranial nerve palsies 3,4,6 • Cxns: Chronic ocular inflammation, vision loss, neuralgia, late corneal sequelae

  24. Acute angle closure glaucoma • Risk Fx:Family Hx, contralateral eye, hyperopia, Asian race, age • Hx: Sudden eye pain, photophobia, halos • PE: Shallow anterior chamber, iris bombe, middilated pupil, hazy cornea, elevated IOP • Tx: one drop each of: 0.5% timolol 1%, apraclonidine, and 2% pilocarpine. Oral acetazolamide, IV mannitol • Ensure pressure drops within an hour

  25. Acute angle closure glaucoma • Complete occlusion of the anterior chamber angle by iris tissue

  26. Iritis • Causes: • Infections, eye disorders, systemic disorders • Trauma, autoimmune disorders, VZV, lyme disease, leukemia/lymphoma, idiopathic • Photophobia and dull ache • Urgent referral to ophtho • Get baseline IOP and start Predforte drops and cycloplegics

  27. Ciliary flare of iritis • Intense injection at limbus

  28. What is this?

  29. Subconjunctival hemorrhage • Causes • Valsalva • Coagulopathy • Presentation • Visual acuity • Absence of pain • Absence of photophobia • Absence of discharge • Should resorb in 1-2 weeks

  30. This eye is not red • And that is the problem. • Alkali chemical burn- large corneal epithelial defect and scleral ischemia.

  31. Of all the conditions you have seen today, this is the fastest to destroy an eye, and can have the worst prognosis • You have only minutes to diagnose and irrigate • Morgan lens, many litres • Afterward:confirm pH, slit lamp exam for corneal defect, r/o deposits in conjunctival recesses.

  32. Chemosis • Insidious onset • Consider retro-orbital causes: mass, aneurysm.

  33. Corneal ulcer with hypopyon

  34. What is this?

  35. What is this?

  36. Blepharitis • Chronic recurrent eyelid inflammation • Staph aureus or seborrhea (pityrosporum) • Warm lid compresses • Topical antibiotic eyedrops+/- ointment • Dandruff shampoos to scalp to eradicate pityrosporum • Slow response

  37. What is this?

  38. Stye • Hordeolum- acute, painful • Chalzion- chronic, non painful • Hot compresses, milking • Refer if not resolving for I+C • Chronic lesions- ? Biopsy to r/o CA

  39. Corneal edema • Note irregular corneal light reflex

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