Evaluating “Red” and “White” Eye

1. Evaluating “Red” and “White” Eye

2. Objectives • Identify important questions and physical exam findings when evaluating red or white eyes • Know the serious diagnoses for which immediate referral to ophthalmology may be recommended

3. Review of the Anatomy

4. Case • You get a phone call from a concerned parent about their 5 year old daughter who is complaining of left eye pain that started abruptly after playing outside all day. She has a foreign body sensation and is unable to open her eye. You have her brought to your clinic immediately and note that she indeed has difficulty opening her left eye and has significant photophobia, a pinpoint pupil, and ciliary flush on physical exam. She has a positive fluorescein stain. She does not know if her vision is affected.

5. Ciliary Flush • Definition - dilation of deep conjunctival vessels and episcleral vessels causing perilimbal redness

6. What questions would you want to ask?

7. Review of the “questions” • Vision impaired? • Foreign body sensation? • Trauma? • Photophobia? • Wear contacts? • Discharge throughout day? • Eyelid involvement?

8. What questions should you ask? • Is vision impaired? • If yes – should be referred to ophthalmologist • Is there a foreign body sensation that prevents the opening of the eye? • Fluorescein may be appropriate to examine for a corneal process • Was there trauma?

9. What questions should you ask? • Is there photophobia? • If yes, do a pen light test by shining pen light into affected eye. In general if patient does not close their eyes and there is no corneal opacity there is likely no corneal process • Do you wear contacts? • If yes, suspect keratitis

10. Keratitis • Definition - condition in which cornea, the front part of the eye, becomes inflamed

11. What questions should you ask? • Is there discharge that persists throughout the day? • If no – not likely bacterial • Early morning crustiness is often mistaken as pus • Is the eyelid involved? • If yes but no other symptoms – think lid pathology

12. Most Common Etiologies with “Red” or “Pink” Eye • Conjunctivitis • Viral or Bacterial • Viral – clear, watery discharge that is ‘stringy’ (mucous and not pus) • often caused by adenovirus & often part of viral prodrome (fever, adenopathy, pharyngitis, URI sx) • Usually bilateral • self-limited, but may last 2-3 weeks • Bacterial – thick, globular, white, green, or yellow discharge that persists throughout the day and reappears quickly if wiped away; most commonly staph aureus, strep pneumo, m. catarrhalis, H. flu • Allergic or non-allergic • Allergic – secondary to aeroallergens contacting the eye; IgE mediated inflammation; often bilateral, diffuse redness, watery discharge, and itchiness • Non-allergic – dry eyes, post exposure-irrigation

13. Most Common Etiologies with “Red” or “Pink” Eye • Can’t miss: • Bacterial keratitis – common in contact lens wearers and corneal abrasions • Iritis - form of anterior uveitis and refers to the inflammation of the iris of the eye • Acute angle closure glaucoma - less common in peds, patients look toxic, describe severe pain, malaise, often a unilateral headache, and may develop nausea and vomiting • Trauma – if subconjunctival hemorrhage and story of trauma, r/o ruptured globe or retrobulbar hemorrhage • Refer to an ophthalmologist for any of the following: • corneal infiltrate • unilateral red eye in an uncomfortable patient with nausea and vomiting • severe eye pain or vision deficit in red eye

14. Therapies • Viral/allergic/non-allergic – self-limited but ok to use topical antihistamines/decongestants (Naphcon, Ocuhist), nonantibiotic lubricants, or re-wetting drops • Bacterial – erythromycin ophthalmic ointment – 1/2” to lower eyelid QID x 5 days, sulfacetamide ophthalmic drops, or fluoroquinolone ophthalmic drops • Return to work? – best case scenario is after discharge is over, however this is unrealistic for many, so most schools/daycares require 24 hrs

15. Iritis

16. Pen Light Test • Pupil reaction – fixed, dilated? – think acute angle closure glaucoma; pinpoint? – think corneal abrasion, keratitis, iritis • Purulent discharge? – if so, consider bacterial conjunctivitis or keratitis; • What is the pattern of the redness? – if diffuse, think conjunctivitis (allergic/viral/bacterial/toxic/nonspecific); if ciliary flush is present, i.e., when the limbus (cornea/sclera junction) is red and diminishes toward the edge of the eye, consider more serious etiologies • Is there an opacity? - if the cornea has a white spot or opacity, think bacterial keratitis • In the anterior chamber is there a hypopyon (layer of white cells) or hyphema (layer of red cells)? – if so, refer to an ophthalmologist • Bonus step: fluorescein stain to eval further – foreign body will not pick up stain but other corneal pathologies will.

17. “White” Eye

18. Questions you want to ask? • Prenatal and birth history? – specifically ask about exposures, prenatal infections, etc. • Perinatal history? – perinatal infections, ICU admission, O2 administration? • Exposure to pets (cats/dogs)? – screens for toxoplasmosis and toxocariasis • Current meds? – corticosteroids predispose to cataracts • Family history? – evaluate for history of retinoblastoma or other eye tumors • Growth pattern? FTT? Development? – evaluate for systemic illnesses

19. Common Diagnoses • Retinoblastoma – up to 47% of cases • Retinopathy of prematurity • Cataract • Coloboma • Uveitis • Toxocariasis • Vitreous hemorrhage • Coat’s disease

20. WHAT IS WHAT? Cataract Vitreous Hemorrhage Coloboma Retinoblastoma Retinopathy of Prematuriy Uveitis

21. Fluroscein Examples A Mild Corneal Abrasion A Severe Corneal Abrasion

22. Summary Points • Not all conjunctivitis, “pink eye”, is bacterial • If any history of trauma, consider foreign body, corneal abrasion or traumatic iritis • If contact lens wearer, consider keratitis (foreign body sensation, inability to open the eye, typically with a corneal opacity), instruct them to stop wearing contacts, if no improvement in 12-24 hours, refer to an ophthalmologist as perforation can happen as early as 24 hrs • Always refer true leukocaria to an ophthalmologist