The Red Eye and Ocular Trauma

1. The Red Eye and Ocular Trauma Stories from Internship Dr Nicholas Cheng

2. Cases – Case 1 • You are on your first ED shift in Horsham. It’s Saturday morning and you’re the only doctor in ED, you’ve dealt with a few footy injuries, broken arms, ruptured spleen and now for a simple red eye. But then you realise you’ve skipped that week of med school when they showed you how to use the slit lamp… Uh oh.

3. Phew, a letter from the GP accompanies the patient. • “Dear doctor at Horsham ED, this young Aboriginal woman presents with 8 days of unilateral red eye with purulent discharge. I’ve started her on some topical antibiotics but it has not improved. She now has a rash and some swelling around her eye, I’m worried she has periorbital cellulitis.”

5. Papillae vs Follicles

6. Chlamydial Conjunctivitis • Symptoms: Chronic conjunctivitis – Subacute • Signs: Mucopurulent discharge, Large follices predom in inferior fornix • Ix: PCR • Rx: Azithromycin 1g single dose, reportable disease

7. Trachoma • Chronic conjunctivitis, • Third most common cause of blindness worldwide - Leading cause of preventable blindness • Cxs: • Cicatricial change with entropion, trichiasis, dry eye and secondary corneal ulceration and scarring • Rx: WHO SAFE – Surgery, Abx, Face washing, Enviro improvement

8. Conjunctivitis

9. Periorbital Cellulitis • Anatomy: Infection ANTERIOR to orbital septum • Path: Periorbital trauma, dermal infection • Sxs: Normal VA, unilat tender, red, swollen eyelids, low grade fever • Rx: Augmentin 875/125mg BD for 7 days, Warm compresses

11. Orbital Cellulitis • Anatomy: Infection POSTERIOR to orbital septum • Path: Sinus infection, trauma, extension of periorbital cellulitis, haematogenous • Sx: Decreased VA, diplopia, fever, headache • Ex: Proptosis, red swollen eyelids, ophthalmoplegia • Optic nerve involvement? RAPD, disc swelling • Ix: CT Orbit • Rx: IV Abx (fluclox 2g IV QID+ ceftriaxone 2g IV Daily)

13. Case 2 • You survived Horsham ED. Now you’re onto Colorectal surgery at RMH, surely no eyes involved there. • Then goes the dreaded pager. Just a handover from the night intern to say one of your patients had a fall overnight but is fine except for a little bit of a red eye and some bruising under the eye.

14. Subconjunctival haemorrhage

15. Orbital Fractures

16. Orbital Fractures • Signs: Ophthalmoplegia, Diplopia, Initially exophthalmos then enophthalmos, associated hyphaema • Infraorbital nerve involvement – altered cheek, upper lip, upper gum sensation • Anatomy: Which wall of orbit usually fractures? • Rx: Do not blow nose, Abx (cephalexin), consider surgical repair if entrapment/diploplia

17. MCQs • Which of these bones is not part of the medial wall of the orbit? • Zygomatic • Ethmoid • Lacrimal • Maxillary • Sphenoid

19. Case 3 • You’re in RMH ED this time. You’re starting to feel pretty confident with this whole slit lamp thing. You picked up another patient with a red eye, should be a breeze.

20. Sxs: UNILATERAL ocular pain, Photophobia! Mildly decreased VA

21. Iritis • Signs: Think outside in • Conjunctiva – Ciliary injection • Cornea – Keratitic precipitates • Anterior Chamber – Cells, flare, hypopyon • Pupil – Irregular, miotic, posterior synechiae • Path: Idiopathic, HLA B27, Vasculitides, Infection, Sarcoid • Rx: • Mydriatics – atropine 1% BD for 1-2 weeks • Topical steroids – Pred acetate 1% • Analgesia

23. MCQs • Which of these can be used as mydriatics? • Tropicamide 0.5% • Phenylephrine • Cocaine 10% • Cyclopentolate • Atropine Parasymp Antagonist – 2-6hours Sympathetic Agonist Sympathetic Agonist Parapsymp Antagonist – 24hours Parapsymp Antagonist – 7-14days

24. Case 4 • You come home from work, luckily no red eyes at work today. Your grandfather is waiting for you at home with a facial rash and a red eye.

25. Sxs: Prodromal phase of tiredness, fever, headache – Painful rash

26. Herpes Zoster Ophthalmicus • Signs: UNILATERAL dermatomal rash, Hutchinson’s Sign = If side of nose is involved then eye will be involved in 75% (Which nerve?) • Small dendritic lesions tapered ends without terminal bulbs = Pseudodendrite • Punctate Epithelial Erosions

27. Herpes Zoster Ophthalmicus • Cxs: Conjunctivitis, iritis, episcleritis/scleritis, keratitis, postherpetic neuralgia • Rx: Aciclovir PO 800mg 5X/day for 3-7 days • Symptomatic – Cold compresses

28. MCQs Which of these cause unilateral red eye?. • HSV keratitis • Retinal detachment • Anterior Ischaemic Optic Neuropathy • Optic neuritis • Acute angle closure glaucoma

29. Framework for the Red Eye

30. Framework for the Red Eye

31. BEWARE the Unilateral Red Eye

32. Hx – Key Questions • Unilateral vs Bilateral • Discharge • Purulent? • Watery? • Pain/Discomfort? • Photophobia? • Grittiness? • Vision affected? • POphHx + PMHx • Allergy/Atopy? • HLA B27 Associated diseases? • Contact lens wearer

33. Ex - Key • Visual Acuity • Pupils • Eye Movements • Visual Fields • Fluoroscein, Eyelid inversion

34. Sxs: Pain +++, lacrimation, FB sensation, decreased VA, Contact lens wear

35. Keratitis • Path: Bacterial - Staph, Strep, Hib, Nesseria, Pseudomonas, Viral – HSV, HZO • Signs: Stains with fluoroscein • Ix: Corneal scrape • Rx: DO NOT GIVE topical steroids, Broad spectrum Abx (fluoroquinolone, gent, vanc, cefazolin) HSV - aciclovir 3% 5X/day for 14days

36. Sxs: Headache, nausea, vomiting, Pain +++, Blurred vision, haloes

37. Acute Angle Closure Glaucoma • Signs: VA 6/60 – Think outside in • Cornea – cloudy • Anterior chamber – shallow, aqueous flare and cells • Pupil - mid-dilated non-reacting • High IOP • Rx: Acetozolamide 500mg IV or PO, topical timolol 0.5%, pilocarpine 1% • Definitive Rx: YAG laser iridotomy

38. Demographics: Females 75% Sxs: Sudden onset redness (hours), mild pain but with no radiation, hotness, discomfort, recurrent, may flit from one eye to the other

39. Episcleritis • Path: Idiopathic, Infectious, rosacea, atopy 80% simple, 20% nodular • Signs: Sectoral or diffuse, peaks within 12hours and fades over 10-21 days • Rx: Topical steroids (FML 0.1%), lubricants, if recurrent – oral NSAIDs

40. Demographics: Females, Fifth decade Sxs: Ocular redness followed few days later by aching pain spreading to face + temple, wakes pt at night, responds poorly to analgesics, decreased vision

41. Scleritis • Signs: Diffuse redness + erythema, tender to touch, inflammation of sclera and episcleral vessels, failure to blanch with topical 10% phenylephrine • Associations: Underlying systemic disease in >50% HLA B27 (AS, Psoriatic, IBD, RA), Vasculitides (SLE, PAN, Wegener’s), Sjogrens, Infective (TB, Syphilis), Sarcoidosis • Rx: Simple scleritis – Oral NSAIDs, then systemic steroids (pred 1mg/kg for 1 week) Necrotising scleritis – High dose IV steroids, Cytotoxic agents (AZA, MTX, Cyclophos, Immunomodulators (ciclosporin, tacrolimus)

42. Trauma • Corneal abrasion • Foreign body • Blunt / Penetrating injury • Burns • Lid / Orbital injury

43. Sxs: Pain ++, Photophobia, Foreign body sensation

44. Corneal Abrasion • Signs: Fluoroscein staining, Evert upper eyelid! • Rx: Topical chlorsig, eye pad • Golden Eye Rule: Should heal within 24 hours if cause is removed

45. Blunt Injury • Corneal abrasion • Subconjunctival haemorrhage • Hyphaema • Vitreous haemorrhage • Orbital #s • Globe rupture

47. Hyphaema • Rx: • Admit to hospital – 5 days bed rest, elevate head • Stop Aspirin or NSAIDs • Eye shield • Mydriatic – Atropine to stop iris movement • Measure IOP, Should resolve in 10-21 days

49. Corneal Foreign Body • Rx: Topical anaesthetic, Cotton bud, 25G needle • After – Chlorsig ointment + eye pad • Do NOT attempt if: central, infected